RN Registered Nurse: Reduction of Risk Potential 3 — Questions and Answers
Question 1: A nurse is caring for a patient receiving a blood transfusion who develops sudden chills, back pain, and dark urine after 50 mL has infused. What is the nurse's priority action?
- Slow the infusion rate and notify the provider
- Stop the transfusion and keep the IV line open with normal saline (Correct answer)
- Administer diphenhydramine IV and continue the transfusion
- Obtain a repeat blood type and crossmatch
Correct answer: Stop the transfusion and keep the IV line open with normal saline
These signs indicate an acute hemolytic transfusion reaction; the transfusion must be stopped immediately and the line kept open with normal saline.
Question 2: Which patient is at highest risk for developing a pulmonary embolism postoperatively?
- A 25-year-old who had a laparoscopic appendectomy and ambulates 4 hours post-op
- A 68-year-old who had a total hip replacement and remains on bed rest (Correct answer)
- A 40-year-old who had a cholecystectomy and is receiving IV fluids
- A 55-year-old who had an inguinal hernia repair and has mild hypertension
Correct answer: A 68-year-old who had a total hip replacement and remains on bed rest
Older age, orthopedic surgery, and immobility are all major risk factors for deep vein thrombosis and subsequent pulmonary embolism.
Question 3: A nurse is inserting a nasogastric tube. After placement, which method best confirms correct placement before beginning a feeding?
- Instilling air and auscultating over the stomach
- Aspirating stomach contents and testing pH (Correct answer)
- Observing for respiratory distress
- Measuring the external length of the tube
Correct answer: Aspirating stomach contents and testing pH
Aspirating gastric contents and testing the pH (≤5.5 confirms gastric placement) is the most reliable bedside method before a chest X-ray.
Question 4: A nurse notes that a patient's surgical wound has new separation with yellow drainage. What is the most appropriate nursing response?
- Apply a sterile dressing and document the finding
- Notify the surgeon and apply a moist sterile dressing (Correct answer)
- Culture the wound and irrigate with hydrogen peroxide
- Place the patient in reverse Trendelenburg position
Correct answer: Notify the surgeon and apply a moist sterile dressing
Wound dehiscence with purulent drainage suggests infection and requires immediate provider notification and appropriate wound care.
Question 5: A patient is prescribed potassium chloride 40 mEq IV. The nurse should administer this over what minimum time frame?
- 5 minutes
- 15 minutes
- 1 hour (Correct answer)
- 4 hours
Correct answer: 1 hour
IV potassium must be administered no faster than 10-20 mEq/hour to avoid life-threatening cardiac arrhythmias.
Question 6: A nurse is caring for a patient with a chest tube. Which finding requires the most immediate intervention?
- Intermittent bubbling in the water-seal chamber during exhalation
- Tidaling in the water-seal chamber with respirations
- Continuous bubbling in the water-seal chamber (Correct answer)
- Approximately 50 mL of blood in the drainage collection chamber
Correct answer: Continuous bubbling in the water-seal chamber
Continuous bubbling in the water-seal chamber indicates an air leak in the system that must be identified and corrected immediately.
Question 7: Which patient teaching point is the priority for a patient newly prescribed lithium carbonate?
- Avoid foods high in vitamin K
- Maintain consistent dietary sodium intake (Correct answer)
- Take the medication on an empty stomach only
- Limit fluid intake to 1 liter per day
Correct answer: Maintain consistent dietary sodium intake
Fluctuations in sodium intake alter lithium renal excretion; low sodium causes lithium retention and increases toxicity risk.
RN Registered Nurse: Reduction of Risk Potential 3
A nurse is caring for a patient receiving a blood transfusion who develops sudden chills, back pain, and dark urine after 50 mL has infused.
What is the nurse's priority action?