NCLEX Reduction of Risk Potential 2

Question 1

A client's serum potassium level is 6.8 mEq/L. Which finding requires the nurse's immediate attention?

Accepted Answer

Peaked T waves on the ECG

Answer

Peaked T waves indicate cardiac membrane instability from hyperkalemia and can progress to lethal dysrhythmias.

Question 2

Before a paracentesis, which nursing action reduces the client's risk of injury?

Accepted Answer

Having the client empty the bladder

Answer

Emptying the bladder lowers the risk of accidental bladder puncture during needle insertion.

Question 3

A client is scheduled for an MRI. Which item must the nurse ensure is removed or addressed?

Accepted Answer

Implanted cardiac pacemaker

Answer

A pacemaker contains ferromagnetic components and electronics that the strong magnetic field can disrupt, posing serious harm.

Question 4

Which lab value should the nurse review before a client receives a contrast dye CT scan?

Accepted Answer

Serum creatinine

Answer

Contrast dye is nephrotoxic, so baseline renal function via creatinine must be assessed to reduce kidney injury risk.

Question 5

A client on warfarin has an INR of 5.2. Which action does the nurse anticipate?

Accepted Answer

Holding the next warfarin dose

Answer

An INR of 5.2 is above therapeutic range and increases bleeding risk, so warfarin is held to reduce that risk.

NCLEX Practice Test