Reduction of Risk Potential

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?

Accepted Answer

The client's serum creatinine is 2.8 mg/dL

Answer

The client is allergic to tree nuts

Answer

The client reports claustrophobia

Answer

The client has not eaten for 4 hours

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?

Accepted Answer

The client's respiratory rate is 8 breaths per minute

Answer

The client's pain rating is 5 out of 10 one hour after a PCA dose

Answer

The client reports mild nausea after receiving a PCA dose

Answer

The client's oxygen saturation is 96% on room air

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?

Accepted Answer

Keep the head of the bed elevated at 30 to 45 degrees at all times

Answer

Position the client supine with the bed flat to promote gastric emptying

Answer

Check gastric residual volumes every 8 hours and continue regardless of volume

Answer

Flush the tube with 10 mL of water every 12 hours

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?

Accepted Answer

Obtain a time-limited provider order and attempt less restrictive alternatives first

Answer

Apply the restraints immediately since the client is a fall risk

Answer

Ask the family's permission to apply restraints without a provider order

Answer

Document the need for restraints and apply them at the nurse's discretion

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?

Accepted Answer

Assess the client's condition and vital signs immediately

Answer

Complete an incident report and notify the charge nurse before assessing the client

Answer

Document the error in the client's medical record and wait to see if symptoms develop

Answer

Notify the family of the error before contacting the provider

Question 6

A nurse is preparing to draw blood from a client with a latex allergy. Which action is most important?

Accepted Answer

Use latex-free gloves and ensure all supplies in contact with the client are latex-free

Answer

Use standard latex gloves and complete the procedure quickly to minimize contact

Answer

Apply antihistamine cream to the venipuncture site before the procedure

Answer

Check the client's allergy wristband and proceed with the standard supply cart