RN Registered Nurse: Reduction of Risk Potential 2 — Questions and Answers
Question 1: A nurse is reviewing a patient's medication list before surgery. Which finding requires the most immediate action?
- The patient takes a daily multivitamin
- The patient takes warfarin 5 mg daily (Correct answer)
- The patient takes metformin 500 mg twice daily
- The patient takes lisinopril 10 mg daily
Correct answer: The patient takes warfarin 5 mg daily
Warfarin must be discontinued before surgery to reduce the risk of excessive bleeding and is the most critical finding.
Question 2: Which laboratory value should the nurse report immediately to the provider before administering digoxin?
- Sodium 138 mEq/L
- Potassium 2.8 mEq/L (Correct answer)
- Calcium 9.2 mg/dL
- Magnesium 1.8 mg/dL
Correct answer: Potassium 2.8 mEq/L
Hypokalemia (potassium < 3.5 mEq/L) increases the risk of digoxin toxicity and must be reported before administration.
Question 3: A patient is scheduled for a contrast CT scan. Which assessment finding is most important to report to the radiologist?
- Allergy to shellfish
- Serum creatinine of 2.4 mg/dL (Correct answer)
- Blood pressure of 148/88 mmHg
- Heart rate of 92 beats/min
Correct answer: Serum creatinine of 2.4 mg/dL
An elevated creatinine indicates impaired renal function, which increases the risk of contrast-induced nephropathy.
Question 4: A nurse administers a subcutaneous injection of insulin to the wrong patient. What is the nurse's first action?
- Document the incident in the medical record
- Notify the nursing supervisor
- Assess the patient's blood glucose level (Correct answer)
- Complete an incident report
Correct answer: Assess the patient's blood glucose level
The immediate priority is to assess the patient's blood glucose to identify hypoglycemia and initiate treatment as needed.
Question 5: Which intervention is the nurse's priority when caring for a patient in skeletal traction?
- Providing high-fiber diet education
- Assessing pin sites for signs of infection (Correct answer)
- Encouraging ambulation every 2 hours
- Applying sequential compression devices
Correct answer: Assessing pin sites for signs of infection
Pin site infection is a serious complication of skeletal traction and requires routine assessment to detect early signs.
Question 6: A post-operative patient's SpO2 drops to 88%. After repositioning the patient, the SpO2 remains at 90%. What is the nurse's next action?
- Document the finding and continue to monitor
- Apply supplemental oxygen as ordered (Correct answer)
- Prepare for emergent intubation
- Administer a bronchodilator
Correct answer: Apply supplemental oxygen as ordered
An SpO2 of 90% is below the normal threshold and supplemental oxygen should be applied per protocol to prevent further hypoxia.
Question 7: Which action best reduces the risk of a wrong-site surgical procedure?
- Reviewing the operative consent form before the patient is sedated
- Asking the surgeon to initial the operative site
- Performing a time-out immediately before the incision (Correct answer)
- Confirming the patient's identity using two identifiers
Correct answer: Performing a time-out immediately before the incision
The surgical time-out performed immediately before the incision is the last line of defense to confirm correct patient, site, and procedure.
RN Registered Nurse: Reduction of Risk Potential 2
A nurse is reviewing a patient's medication list before surgery.
Which finding requires the most immediate action?