Reduction of Risk Potential 3

Question 1

A nurse is reviewing lab results for a client with heart failure. Which finding should the nurse report to the provider immediately?

Accepted Answer

Serum potassium of 2.8 mEq/L

Answer

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?

Accepted Answer

Elevate the head of bed to 30 degrees with head in neutral position

Answer

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?

Accepted Answer

Absence of right dorsalis pedis pulse

Answer

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?

Accepted Answer

Uncompensated respiratory acidosis

Answer

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"?

Accepted Answer

Flushing, erythema, and pruritus of the face and upper trunk

Answer

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.

NCLEX Practice Test

NCLEX Practice Test

Reduction of Risk Potential 3