Reduction of Risk Potential Flashcards
7 cards from real NCLEX practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Reduction of Risk Potential flashcards as text
A client receiving a blood transfusion develops fever, chills, and low back pain after 15 minutes. What is the nurse's priority action?
Answer: Stop the transfusion immediately
These signs suggest an acute hemolytic reaction, and stopping the transfusion prevents further harm.
Which value indicates the client on heparin therapy is at increased risk for bleeding?
Answer: aPTT of 120 seconds
An aPTT of 120 seconds exceeds the therapeutic range, indicating excessive anticoagulation and bleeding risk.
Before administering digoxin, the nurse notes an apical pulse of 52 beats/min. What should the nurse do?
Answer: Hold the dose and notify the provider
Digoxin is withheld when the apical pulse is below 60 beats/min to prevent further bradycardia.
A client's pulse oximetry reads 86% on room air. Which action reduces the client's risk first?
Answer: Apply supplemental oxygen
An oxygen saturation of 86% indicates hypoxemia, and applying oxygen is the immediate intervention to reduce harm.
Which finding in a postoperative client most strongly suggests internal hemorrhage?
Answer: Falling blood pressure with rising pulse
Hypotension with tachycardia reflects the body's compensatory response to blood loss.
A client with a chest tube has continuous bubbling in the water-seal chamber. What does this indicate?
Answer: An air leak in the system
Continuous bubbling in the water-seal chamber signals an air leak that must be located and corrected.
Which lab result should the nurse report before a client receives metformin and contrast dye?
Answer: Elevated serum creatinine
Elevated creatinine with metformin and contrast increases the risk of lactic acidosis and acute kidney injury.