Reduction of Risk Potential 3 — Questions and Answers
Question 1: A nurse is reviewing lab results for a client with heart failure. Which finding should the nurse report to the provider immediately?
- BNP of 850 pg/mL
- Serum potassium of 2.8 mEq/L (Correct answer)
- Urine output of 45 mL/hour
- SpO2 of 94% on 2L nasal cannula
Correct answer: Serum potassium of 2.8 mEq/L
A serum potassium of 2.8 mEq/L is hypokalemia (normal 3.5–5.0 mEq/L). Clients with heart failure are often on loop diuretics (e.g., furosemide) which deplete potassium. Hypokalemia in a client likely taking digoxin (common in heart failure) dramatically increases the risk of digoxin toxicity and life-threatening dysrhythmias including ventricular fibrillation. This must be reported immediately.
Question 2: A nurse is caring for a client with increased intracranial pressure (ICP). Which nursing action helps reduce ICP?
- Position the client in Trendelenburg to improve cerebral perfusion
- Cluster all nursing care to allow uninterrupted rest periods
- Elevate the head of bed to 30 degrees with head in neutral position (Correct answer)
- Encourage coughing and deep breathing every 2 hours
Correct answer: Elevate the head of bed to 30 degrees with head in neutral position
Elevating the head of the bed to 30 degrees and maintaining neutral head position facilitates venous drainage from the brain via the jugular veins, which reduces cerebral blood volume and ICP. This is a standard, evidence-based intervention for managing elevated ICP. Flexion of the neck, Trendelenburg position, or hip flexion greater than 90 degrees all impede venous drainage and worsen ICP.
Question 3: A nurse is caring for a client post-cardiac catheterization via the right femoral artery. Which assessment finding requires immediate intervention?
- Mild bruising at the puncture site
- Client complaint of discomfort when walking to the bathroom
- Absence of right dorsalis pedis pulse (Correct answer)
- Urine output of 40 mL in the past hour
Correct answer: Absence of right dorsalis pedis pulse
After femoral artery catheterization, a hematoma or expanding mass at the puncture site with a palpable thrill and bruit may indicate a femoral artery pseudoaneurysm. However, a sudden loss of the dorsalis pedis pulse on the right foot indicates arterial occlusion — a vascular emergency requiring immediate intervention to restore blood flow and prevent limb ischemia or loss. Absent pulses always take priority.
Question 4: A client's ABG results show: pH 7.30, PaCO2 52 mmHg, HCO3 24 mEq/L. How should the nurse interpret these results?
- Compensated metabolic acidosis
- Uncompensated respiratory alkalosis
- Uncompensated respiratory acidosis (Correct answer)
- Compensated respiratory acidosis
Correct answer: Uncompensated respiratory acidosis
ABG interpretation: pH 7.30 is acidosis (normal 7.35–7.45). PaCO2 52 mmHg is elevated (normal 35–45), indicating the problem is respiratory (CO2 is an acid — elevated CO2 = more acid). HCO3 24 mEq/L is normal (normal 22–26), meaning the kidneys have not yet compensated. Therefore, this is uncompensated respiratory acidosis, commonly seen in hypoventilation, COPD exacerbation, or sedation.
Question 5: A nurse is monitoring a client receiving IV vancomycin. Which finding indicates the client is experiencing "Red Man Syndrome"?
- Sudden drop in blood pressure and loss of consciousness
- Flushing, erythema, and pruritus of the face and upper trunk (Correct answer)
- Elevated serum creatinine and decreased urine output
- Tinnitus and hearing loss
Correct answer: Flushing, erythema, and pruritus of the face and upper trunk
Red Man Syndrome is a non-immune-mediated infusion reaction to vancomycin caused by too-rapid infusion. It is characterized by flushing, erythema (redness), and pruritus (itching) primarily of the face, neck, and upper torso — sometimes called the "red man" pattern. It is NOT a true allergic reaction but requires stopping or slowing the infusion and administering antihistamines. It is distinct from anaphylaxis.
Question 6: A nurse is caring for a client who is 24 hours post-appendectomy. Which assessment finding most warrants notifying the provider?
- Hypoactive bowel sounds in all four quadrants
- Temperature of 38.9°C with abdominal rigidity (Correct answer)
- Mild incisional pain rated 4/10
- Serosanguineous drainage on the surgical dressing
Correct answer: Temperature of 38.9°C with abdominal rigidity
A fever of 38.9°C (102°F) 24 hours post-appendectomy along with abdominal rigidity and guarding are signs of peritonitis, suggesting possible rupture or anastomotic leak. This is a surgical emergency. While mild fever in the first 24–48 hours can be expected from the inflammatory response, a temperature of 38.9°C combined with abdominal rigidity requires immediate provider notification.
Reduction of Risk Potential 3
A nurse is reviewing lab results for a client with heart failure.
Which finding should the nurse report to the provider immediately?