NACE Reduction of Risk Potential 5

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?

Accepted Answer

Hold metformin before and after the procedure as ordered

Answer

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?

Accepted Answer

Seizure activity and decreased level of consciousness

Answer

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?

Accepted Answer

An 80-year-old client who is incontinent, malnourished, and bedridden

Answer

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?

Accepted Answer

Stop the infusion and assess the site for infiltration or phlebitis

Answer

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?

Accepted Answer

Hold the next lithium dose and notify the physician immediately

Answer

These signs indicate lithium toxicity; the nurse must hold the medication and notify the physician immediately to prevent serious neurological and cardiac complications.

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 5