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

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?

Accepted Answer

The client's respiratory rate is 8 breaths per minute

Answer

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?

Accepted Answer

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

Answer

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?

Accepted Answer

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

Answer

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?

Accepted Answer

Assess the client's condition and vital signs immediately

Answer

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.

NCLEX Practice Test

NCLEX Practice Test

Reduction of Risk Potential