RN Registered Nurse: Reduction of Risk Potential 4

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?

Accepted Answer

Stop or reduce the infusion per protocol and notify the provider

Answer

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?

Accepted Answer

Positive Chvostek's sign

Answer

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?

Accepted Answer

GCS score decreasing from 14 to 11 over 2 hours

Answer

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?

Accepted Answer

Having a second nurse perform an independent double-check

Answer

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?

Accepted Answer

Notify the provider and prepare to discontinue the line

Answer

These signs indicate phlebitis or thrombophlebitis; the nurse should notify the provider, as the PICC line may need to be removed.

RN - Registered Nurse Practice Test

RN - Registered Nurse Practice Test

RN Registered Nurse: Reduction of Risk Potential 4