RN Registered Nurse: Reduction of Risk Potential 4 — Questions and Answers
Question 1: A nurse receives handoff for a patient on heparin infusion. The aPTT result is 120 seconds (therapeutic range 60-100 seconds). What is the nurse's priority action?
- Continue the infusion at the current rate
- Increase the infusion rate per protocol
- Stop or reduce the infusion per protocol and notify the provider (Correct answer)
- Administer protamine sulfate immediately
Correct answer: Stop or reduce the infusion per protocol and notify the provider
An aPTT above the therapeutic range indicates supratherapeutic anticoagulation, requiring rate reduction or cessation per protocol and provider notification.
Question 2: Which assessment finding in a post-thyroidectomy patient requires the nurse to immediately notify the provider?
- Mild sore throat and difficulty swallowing
- Positive Chvostek's sign (Correct answer)
- Pain rating of 4/10 at the incision site
- Temperature of 37.8°C (100°F)
Correct answer: Positive Chvostek's sign
A positive Chvostek's sign indicates hypocalcemia from inadvertent parathyroid gland damage, which can lead to life-threatening tetany.
Question 3: A nurse is performing a neurological assessment on a patient with a head injury. Which finding indicates a deteriorating neurological status?
- GCS score decreasing from 14 to 11 over 2 hours (Correct answer)
- Complaint of a mild headache
- Pupils that are equal and reactive to light at 3 mm
- Blood pressure of 130/82 mmHg
Correct answer: GCS score decreasing from 14 to 11 over 2 hours
A declining GCS score indicates worsening neurological function and requires immediate provider notification.
Question 4: A nurse is preparing to administer a high-alert medication. Which safety measure is most important before administration?
- Asking a colleague to witness the administration
- Having a second nurse perform an independent double-check (Correct answer)
- Reviewing the patient's allergy list
- Confirming the medication was prescribed by the provider
Correct answer: Having a second nurse perform an independent double-check
An independent double-check by a second nurse is the key safety strategy for high-alert medications to catch errors before they reach the patient.
Question 5: A patient with a PICC line develops redness and warmth along the vessel pathway proximal to the insertion site. Which action should the nurse take first?
- Flush the line with normal saline
- Apply a warm compress and reassess in one hour
- Remove the PICC line immediately
- Notify the provider and prepare to discontinue the line (Correct answer)
Correct answer: Notify the provider and prepare to discontinue the line
These signs indicate phlebitis or thrombophlebitis; the nurse should notify the provider, as the PICC line may need to be removed.
Question 6: A nurse is preparing a patient for a lumbar puncture. Which position should the nurse help the patient assume?
- Supine with head of bed elevated 30 degrees
- Lateral recumbent with spine flexed and knees drawn to chest (Correct answer)
- Prone with a pillow under the abdomen
- Sitting upright with arms raised above the head
Correct answer: Lateral recumbent with spine flexed and knees drawn to chest
The lateral recumbent (fetal) position with the spine flexed maximizes intervertebral space to facilitate needle insertion.
Question 7: A patient develops stridor and urticaria five minutes after receiving IV penicillin. Which medication should the nurse administer first?
- Diphenhydramine 50 mg IV
- Methylprednisolone 125 mg IV
- Epinephrine 0.3 mg IM (Correct answer)
- Albuterol via nebulizer
Correct answer: Epinephrine 0.3 mg IM
Epinephrine IM is the first-line treatment for anaphylaxis because it rapidly reverses bronchospasm and hypotension.
RN Registered Nurse: Reduction of Risk Potential 4
A nurse receives handoff for a patient on heparin infusion.
The aPTT result is 120 seconds (therapeutic range 60-100 seconds).
What is the nurse's priority action?