NACE Reduction of Risk Potential 4

Question 1

A nurse reviews a client's medication list and notes they are taking warfarin. Which laboratory value is most critical to monitor to reduce risk of bleeding complications?

Accepted Answer

International Normalized Ratio (INR)

Answer

INR is the standard test used to monitor warfarin therapy and guide dosing to prevent hemorrhage.

Question 2

A postoperative client reports sudden onset of chest pain and shortness of breath on day 2 after hip replacement surgery. What is the nurse's priority action?

Accepted Answer

Notify the physician immediately

Answer

Sudden chest pain and dyspnea after orthopedic surgery are classic signs of pulmonary embolism, requiring immediate physician notification.

Question 3

Which nursing intervention best reduces the risk of aspiration in a client receiving continuous enteral tube feedings?

Accepted Answer

Keep the head of bed elevated at 30–45 degrees

Answer

Elevating the head of the bed 30–45 degrees reduces gastroesophageal reflux and the risk of aspiration pneumonia.

Question 4

A client with chronic kidney disease has a serum potassium of 6.2 mEq/L. Which assessment finding requires the nurse's most immediate action?

Accepted Answer

Irregular cardiac rhythm on telemetry

Answer

Hyperkalemia causes cardiac dysrhythmias, which can be life-threatening and require immediate intervention.

Question 5

A nurse is caring for a client receiving a blood transfusion who develops hives, itching, and mild urticaria 15 minutes after the infusion begins. What is the priority nursing action?

Accepted Answer

Stop the transfusion, keep the IV open with normal saline, and notify the physician

Answer

An allergic transfusion reaction requires stopping the transfusion, maintaining IV access with normal saline, and notifying the physician to determine further management.

Nursing Acceleration Challenge Exam (NACE) I PN-RN Practice Test

Nursing Acceleration Challenge Exam (NACE) I PN-RN Practice Test

NACE Reduction of Risk Potential 4