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
Which finding in a client receiving total parenteral nutrition (TPN) requires immediate attention?
Answer: Blood glucose of 320 mg/dL
TPN's high dextrose content can cause hyperglycemia, which requires prompt intervention.
A client is to receive an enema before surgery. Which sign indicates the nurse should stop the procedure?
Answer: Severe abdominal cramping and pallor
Severe cramping with pallor may indicate vagal stimulation or bowel injury, requiring the enema to stop.
Which assessment is the priority before a client undergoes a stress electrocardiogram (stress test)?
Answer: Current chest pain or unstable angina
Active chest pain or unstable angina is a contraindication because exercise can trigger a serious cardiac event.
A client's arterial blood gas shows pH 7.30, PaCO2 55 mm Hg. Which intervention reduces risk?
Answer: Encouraging deep breathing and coughing
These values indicate respiratory acidosis from hypoventilation, so improving ventilation corrects the problem.
Which nursing action reduces the risk of pressure injury in an immobile client?
Answer: Repositioning at least every 2 hours
Frequent repositioning relieves prolonged pressure over bony prominences and prevents tissue breakdown.
A client is prescribed a fall-risk medication. Which environmental measure reduces injury risk?
Answer: Keeping the call light within reach and bed in low position
An accessible call light and a low bed position help prevent falls and injury.
Which finding should the nurse report before a client receives a potassium-sparing diuretic such as spironolactone?
Answer: Serum potassium of 5.6 mEq/L
Spironolactone retains potassium, so an already elevated level increases the risk of dangerous hyperkalemia.