NCSBN - National Council of State Boards of Nursing Reduction of Risk Potential Questions and Answers — Questions and Answers
Question 1: A nurse is reviewing the laboratory results of a client with a potassium level of 2.9 mEq/L. Which of the following assessments is the nurse's priority?
- Assessing the client's cardiac rhythm (Correct answer)
- Monitoring for Chvostek's sign
- Checking for pitting edema in the extremities
- Measuring the client's abdominal girth
Correct answer: Assessing the client's cardiac rhythm
Hypokalemia (a low potassium level) can cause life-threatening cardiac dysrhythmias by altering the electrical stability of the myocardium. Therefore, the priority nursing assessment is to monitor the client's heart rate and rhythm. Chvostek's sign is associated with hypocalcemia, pitting edema relates to fluid volume status, and abdominal girth is not a primary assessment for hypokalemia.
Question 2: A nurse is caring for a client who has just undergone a lumbar puncture. To reduce the risk of a post-dural puncture headache, which intervention should the nurse implement?
- Encourage immediate ambulation to promote circulation.
- Instruct the client to remain in a flat or supine position. (Correct answer)
- Restrict oral fluid intake for the first 4 hours.
- Administer a prophylactic sedative medication.
Correct answer: Instruct the client to remain in a flat or supine position.
Positioning the client flat (supine) after a lumbar puncture helps to decrease the leakage of cerebrospinal fluid (CSF) from the puncture site. This reduces the risk of developing a post-dural puncture headache, which is caused by a decrease in intracranial pressure from CSF loss. Ambulation is discouraged, fluids are encouraged to help replace CSF, and sedatives are not a primary preventative measure.
Question 3: A nurse is preparing a client for a computed tomography (CT) scan of the abdomen with intravenous contrast. Which of the following findings in the client's record requires the most immediate intervention by the nurse?
- A documented history of claustrophobia.
- A reported allergy to shellfish.
- A serum creatinine level of 2.5 mg/dL. (Correct answer)
- The client is currently prescribed metformin.
Correct answer: A serum creatinine level of 2.5 mg/dL.
Intravenous contrast dye is nephrotoxic and can cause acute kidney injury. An elevated serum creatinine level (normal range is typically 0.6-1.3 mg/dL) indicates significant renal impairment. This finding must be reported to the provider immediately as it is a major contraindication to receiving contrast media. While claustrophobia and metformin use are important considerations, severe renal impairment poses the most immediate risk of a serious physiological complication.
Question 4: A nurse is assessing a client who is three days postoperative from a total knee arthroplasty. The client suddenly reports feeling anxious, short of breath, and has a sense of impending doom. Which additional finding would most strongly suggest the development of a pulmonary embolism?
- A productive cough with thick, green sputum.
- Bradycardia with a blood pressure of 90/50 mmHg.
- Swelling, warmth, and redness in the calf.
- An acute onset of pleuritic chest pain and tachypnea. (Correct answer)
Correct answer: An acute onset of pleuritic chest pain and tachypnea.
The classic signs and symptoms of a pulmonary embolism include sudden-onset dyspnea (shortness of breath), pleuritic chest pain (sharp pain on inspiration), anxiety, and tachypnea (rapid breathing). While calf swelling suggests a deep vein thrombosis (DVT), which is a cause of PE, the chest pain and tachypnea are direct signs of the embolism in the lungs. A productive cough suggests infection, and clients with a PE are more likely to be tachycardic.
Question 5: A nurse is initiating a transfusion of packed red blood cells (PRBCs) for a client. Which of the following actions is most critical for the nurse to perform within the first 15 minutes of the infusion?
- Increase the infusion rate to the prescribed maximum.
- Remain with the client and monitor vital signs. (Correct answer)
- Document the client's baseline intake and output.
- Administer an antihistamine to prevent a reaction.
Correct answer: Remain with the client and monitor vital signs.
The majority of severe, life-threatening transfusion reactions occur within the first 15 minutes or the first 50 mL of the infusion. It is a critical safety standard for the nurse to remain with the client during this period to monitor for signs of a reaction, such as fever, chills, back pain, shortness of breath, or hives, and to monitor vital signs per facility policy.
Question 6: A nurse is caring for a client with a new short-leg cast for a fractured tibia. The client reports severe pain in the affected leg that is not relieved by opioid analgesics. The nurse notes the client's toes are pale and cool. What is the nurse's priority action?
- Elevate the casted leg on two pillows.
- Apply a new ice pack over the area of pain.
- Administer the next scheduled dose of pain medication.
- Notify the healthcare provider immediately. (Correct answer)
Correct answer: Notify the healthcare provider immediately.
The combination of severe, unrelieved pain (pain out of proportion to the injury), pallor (paleness), and coolness are hallmark signs of acute compartment syndrome. This is a medical emergency caused by swelling and increased pressure within a confined space, which compromises circulation and can lead to permanent limb damage. The nurse's priority is to notify the provider immediately for urgent intervention, such as bivalving the cast or a fasciotomy. Elevating the limb can worsen the condition by further reducing arterial circulation.
NCSBN - National Council of State Boards of Nursing Reduction of Risk Potential Questions and Answers
A nurse is reviewing the laboratory results of a client with a potassium level of 2.9 mEq/L.
Which of the following assessments is the nurse's priority?