Reduction of Risk Potential — Questions and Answers
Question 1: A nurse is preparing a client for a contrast CT scan of the abdomen. Which assessment finding requires the nurse to notify the provider before proceeding?
- The client is allergic to tree nuts
- The client's serum creatinine is 2.8 mg/dL (Correct answer)
- The client reports claustrophobia
- The client has not eaten for 4 hours
Correct answer: The client's serum creatinine is 2.8 mg/dL
Iodinated contrast dye is nephrotoxic. A creatinine of 2.8 mg/dL indicates compromised renal function, which significantly increases the risk of contrast-induced nephropathy. The provider must decide whether to proceed, prehydrate, or use a non-contrast study. Shellfish allergy was previously considered a contraindication but is no longer the standard predictor.
Question 2: A nurse is caring for a client who is postoperative following abdominal surgery and is receiving a patient-controlled analgesia (PCA) pump with morphine. Which assessment finding is most concerning?
- The client's pain rating is 5 out of 10 one hour after a PCA dose
- The client's respiratory rate is 8 breaths per minute (Correct answer)
- The client reports mild nausea after receiving a PCA dose
- The client's oxygen saturation is 96% on room air
Correct answer: The client's respiratory rate is 8 breaths per minute
A respiratory rate of 8 breaths per minute indicates opioid-induced respiratory depression — the most dangerous complication of PCA therapy. The nurse must stop the PCA, stimulate the client, apply oxygen, and prepare to administer naloxone while notifying the provider.
Question 3: A nurse is caring for a client with a nasogastric tube receiving continuous enteral feedings. Which action best reduces the risk of aspiration?
- Position the client supine with the bed flat to promote gastric emptying
- Check gastric residual volumes every 8 hours and continue regardless of volume
- Keep the head of the bed elevated at 30 to 45 degrees at all times (Correct answer)
- Flush the tube with 10 mL of water every 12 hours
Correct answer: Keep the head of the bed elevated at 30 to 45 degrees at all times
Elevating the head of the bed to 30-45 degrees (reverse Trendelenburg or semi-Fowler's) is the most evidence-based intervention to reduce aspiration risk during enteral feeding. A supine position allows gastric contents to reflux into the esophagus and airway.
Question 4: A nurse is caring for a client who is confused and trying to climb out of bed. Before applying soft wrist restraints, which action must the nurse take?
- Apply the restraints immediately since the client is a fall risk
- Obtain a time-limited provider order and attempt less restrictive alternatives first (Correct answer)
- Ask the family's permission to apply restraints without a provider order
- Document the need for restraints and apply them at the nurse's discretion
Correct answer: Obtain a time-limited provider order and attempt less restrictive alternatives first
Restraints are a last resort. The nurse must first attempt least-restrictive alternatives (bed alarm, frequent reorientation, family presence, low bed position). A valid time-limited provider order is legally required before applying restraints. Restraints can cause injury and psychological harm.
Question 5: A nurse administers a medication and later realizes it was given to the wrong client. The client appears unharmed. Which action should the nurse take first?
- Complete an incident report and notify the charge nurse before assessing the client
- Assess the client's condition and vital signs immediately (Correct answer)
- Document the error in the client's medical record and wait to see if symptoms develop
- Notify the family of the error before contacting the provider
Correct answer: Assess the client's condition and vital signs immediately
Client safety is always the immediate priority. The nurse must first assess the client for any adverse effects from the wrong medication. After ensuring the client is stable, the nurse notifies the provider, completes an incident report, and documents the assessment findings objectively in the medical record.
Question 6: A nurse is preparing to draw blood from a client with a latex allergy. Which action is most important?
- Use standard latex gloves and complete the procedure quickly to minimize contact
- Apply antihistamine cream to the venipuncture site before the procedure
- Use latex-free gloves and ensure all supplies in contact with the client are latex-free (Correct answer)
- Check the client's allergy wristband and proceed with the standard supply cart
Correct answer: Use latex-free gloves and ensure all supplies in contact with the client are latex-free
Clients with latex allergy are at risk for anaphylaxis with any latex exposure, including gloves, tourniquets, and injection ports. The nurse must use latex-free gloves and ensure all equipment contacting the client is latex-free. A latex-safe environment must be established before any procedure.
Reduction of Risk Potential
A nurse is preparing a client for a contrast CT scan of the abdomen.
Which assessment finding requires the nurse to notify the provider before proceeding?