NCSBN - National Council of State Boards of Nursing Reduction of Risk Potential 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?

Accepted Answer

Assessing the client's cardiac rhythm

Answer

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?

Accepted Answer

Instruct the client to remain in a flat or supine position.

Answer

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?

Accepted Answer

A serum creatinine level of 2.5 mg/dL.

Answer

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?

Accepted Answer

An acute onset of pleuritic chest pain and tachypnea.

Answer

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?

Accepted Answer

Remain with the client and monitor vital signs.

Answer

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.

NCSBN - National Council of State Boards of Nursing Practice Test

NCSBN - National Council of State Boards of Nursing Practice Test

NCSBN - National Council of State Boards of Nursing Reduction of Risk Potential Questions and Answers