Reduction of Risk Potential 2

Question 1

A client's morning labs show a serum sodium of 122 mEq/L. Which assessment finding does the nurse anticipate?

Accepted Answer

Confusion, lethargy, and headache

Answer

Normal serum sodium is 135–145 mEq/L. A sodium of 122 mEq/L represents severe hyponatremia. The brain is most sensitive to low sodium; as water shifts into brain cells (cerebral edema), neurological manifestations occur including confusion, lethargy, headache, and in severe cases seizures and coma. These are the expected clinical findings.

Question 2

A nurse is preparing a client for a lumbar puncture. Which position should the nurse assist the client into?

Accepted Answer

Lateral recumbent with back arched and knees drawn to chest

Answer

The lateral recumbent (fetal) position with the back arched, knees drawn to the chest, and chin tucked toward the chest maximizes the space between lumbar vertebrae by flexing the spine. This is the preferred position for lumbar puncture as it widens the intervertebral spaces, making needle insertion between L3-L4 or L4-L5 safer and easier.

Question 3

A post-operative client has a nasogastric (NG) tube. Before administering medications through the tube, which action is the nurse's priority?

Accepted Answer

Verify tube placement by checking gastric aspirate pH

Answer

Verifying NG tube placement before each use is the safety priority to prevent aspiration pneumonia or direct medication instillation into the lungs. The gold standard is to check pH of aspirate (pH ≤5.5 indicates gastric placement) and confirm position via X-ray for newly inserted tubes. Auscultation of air is no longer recommended as the sole method, but aspirating gastric contents and checking pH is the bedside priority.

Question 4

A nurse is monitoring a client receiving a blood transfusion who develops chills, fever (38.9°C), and flank pain 20 minutes into the infusion. Which action should the nurse take first?

Accepted Answer

Stop the transfusion immediately

Answer

These symptoms — fever, chills, and flank pain during a transfusion — are classic signs of an acute hemolytic transfusion reaction, the most dangerous type caused by ABO incompatibility. The immediate priority is to stop the transfusion at once to prevent further hemolysis, which can lead to renal failure, DIC, and death. Stopping the infusion is always the first action before any other interventions.

Question 5

A nurse receives a lab result showing a client's INR is 4.8 while on warfarin therapy for atrial fibrillation. Which action is most appropriate?

Accepted Answer

Hold warfarin and notify the provider immediately

Answer

The therapeutic INR range for atrial fibrillation is 2.0–3.0. An INR of 4.8 is supratherapeutic and places the client at high risk for serious bleeding complications (intracranial hemorrhage, GI bleed). The nurse must hold the next warfarin dose and notify the provider immediately so the dose can be adjusted or reversed. Vitamin K may be ordered depending on clinical assessment.

NCLEX Practice Test

NCLEX Practice Test

Reduction of Risk Potential 2