NACE Reduction of Risk Potential 5 — Questions and Answers
Question 1: A client with diabetes mellitus is prescribed metformin and is scheduled for a CT scan with contrast dye. Which nursing action is most important prior to the procedure?
- Hold metformin before and after the procedure as ordered (Correct answer)
- Administer an insulin sliding scale before the scan
- Encourage the client to increase fluid intake the day before
- Monitor blood glucose every 2 hours post-procedure
Correct answer: Hold metformin before and after the procedure as ordered
Metformin must be held before contrast administration and for 48 hours after because contrast media can impair renal function, causing metformin accumulation and lactic acidosis.
Question 2: A nurse receives shift report on a client with a serum sodium of 122 mEq/L. Which clinical manifestation is most critical to assess for immediately?
- Dry mucous membranes and poor skin turgor
- Seizure activity and decreased level of consciousness (Correct answer)
- Orthostatic hypotension and tachycardia
- Muscle cramps and hyperreflexia
Correct answer: Seizure activity and decreased level of consciousness
Severe hyponatremia (sodium <125 mEq/L) causes cerebral edema, leading to seizures and altered consciousness, which are life-threatening.
Question 3: Which client is at highest risk for developing pressure injuries and requires the most intensive skin assessment?
- A 45-year-old ambulatory client with controlled hypertension
- An 80-year-old client who is incontinent, malnourished, and bedridden (Correct answer)
- A 60-year-old client with type 2 diabetes who walks with assistance
- A 70-year-old client with mild cognitive impairment who is alert and mobile
Correct answer: An 80-year-old client who is incontinent, malnourished, and bedridden
Advanced age, immobility, incontinence, and malnutrition are all major independent risk factors that together create the highest risk profile for pressure injury.
Question 4: A nurse is administering an IV piggyback antibiotic when the client reports burning and swelling at the IV site. Which action should the nurse take first?
- Slow the infusion rate and apply a warm compress
- Stop the infusion and remove the IV catheter
- Stop the infusion and assess the site for infiltration or phlebitis (Correct answer)
- Flush the line with normal saline and continue the infusion
Correct answer: Stop the infusion and assess the site for infiltration or phlebitis
The nurse must first stop the infusion and assess whether burning and swelling indicate infiltration, phlebitis, or extravasation before determining next steps.
Question 5: A client taking lithium carbonate reports nausea, vomiting, coarse hand tremors, and confusion. Which nursing action is the priority?
- Administer an antiemetic and reassure the client
- Hold the next lithium dose and notify the physician immediately (Correct answer)
- Encourage increased fluid and sodium intake
- Obtain a serum lithium level and continue scheduled doses
Correct answer: Hold the next lithium dose and notify the physician immediately
These signs indicate lithium toxicity; the nurse must hold the medication and notify the physician immediately to prevent serious neurological and cardiac complications.
Question 6: A postpartum client develops sudden severe headache, blurred vision, and a blood pressure of 158/104 mmHg on day 2 after delivery. Which is the nurse's priority action?
- Position the client in left lateral recumbent position and document findings
- Administer prescribed PRN analgesic for headache relief
- Notify the physician immediately and prepare for magnesium sulfate administration (Correct answer)
- Encourage oral hydration and reassess blood pressure in 30 minutes
Correct answer: Notify the physician immediately and prepare for magnesium sulfate administration
These findings indicate postpartum preeclampsia, a medical emergency requiring immediate physician notification and magnesium sulfate to prevent eclamptic seizures.
Question 7: A nurse is caring for a client who had a thyroidectomy 12 hours ago. Which finding requires the most immediate intervention?
- Mild sore throat and hoarse voice
- Serum calcium of 7.2 mg/dL with positive Chvostek's sign (Correct answer)
- Surgical site with scant serosanguineous drainage
- Pain rated 4/10 relieved by prescribed analgesic
Correct answer: Serum calcium of 7.2 mg/dL with positive Chvostek's sign
Hypocalcemia after thyroidectomy caused by inadvertent parathyroid removal can lead to tetany and laryngospasm, requiring immediate intervention.
NACE Reduction of Risk Potential 5
A client with diabetes mellitus is prescribed metformin and is scheduled for a CT scan with contrast dye.
Which nursing action is most important prior to the procedure?