Nursing Acceleration Challenge Exam I PN-RN Reduction of Risk Potential Questions and Answers

Question 1

A nurse is reviewing the laboratory results for a client receiving warfarin therapy. The client's International Normalized Ratio (INR) is 4.5. Which action should the nurse take first?

Accepted Answer

Hold the next dose of warfarin and notify the healthcare provider.

Answer

Administer the next scheduled dose of warfarin.

Answer

Prepare to administer protamine sulfate.

Answer

Document the finding as within the therapeutic range.

Question 2

A nurse is preparing to assist with a thoracentesis for a client with a large pleural effusion. To reduce the risk of puncturing the lung, which position should the nurse assist the client into?

Accepted Answer

Seated on the edge of the bed, leaning forward over a bedside table.

Answer

Lying flat in a supine position.

Answer

In a side-lying position with the affected side up.

Answer

In Trendelenburg position.

Question 3

A nurse is creating a plan of care for a client newly diagnosed with an acute deep vein thrombosis (DVT) in the left leg. Which of the following nursing interventions should be included in the plan?

Accepted Answer

Elevating the affected extremity while the client is in bed.

Answer

Massaging the affected calf gently to reduce pain.

Answer

Applying sequential compression devices (SCDs) to both legs.

Answer

Encouraging active range-of-motion exercises for the affected leg.

Question 4

A client preparing for a colonoscopy is consuming the prescribed polyethylene glycol solution and reports feeling nauseated and bloated. The client states, "I don't think I can drink any more of this." Which nursing response is most appropriate to reduce the risk of an incomplete bowel preparation?

Accepted Answer

"You can take a short break for about 30-60 minutes, then resume drinking the solution at a slower pace."

Answer

"It's important to finish the prep; try to drink the rest as quickly as possible."

Answer

"I will bring you some solid food to help settle your stomach."

Answer

"Stop drinking the solution immediately and we will notify the doctor to cancel the procedure."

Question 5

The nurse is assessing a client who is 72 hours postoperative following a total hip arthroplasty. Which assessment finding is most indicative of a potential pulmonary embolism and requires immediate notification of the provider?

Accepted Answer

Sudden onset of shortness of breath and pleuritic chest pain.

Answer

Pain at the surgical site rated 4 out of 10.

Answer

Scant serosanguineous drainage on the surgical dressing.

Answer

Temperature of 99.8°F (37.7°C) and diminished breath sounds in the lung bases.

Question 6

A nurse is caring for a client on prolonged bed rest. To reduce the client's risk of developing renal calculi, which intervention is the highest priority?

Accepted Answer

Ensuring a fluid intake of 2,500 to 3,000 mL per day.

Answer

Providing a low-calcium diet.

Answer

Administering prophylactic antibiotics.

Answer

Assisting the client to a high-Fowler's position for all meals.