RN Registered Nurse: Reduction of Risk Potential 5 — Questions and Answers
Question 1: A nurse is assessing a patient who has been receiving total parenteral nutrition (TPN) for 5 days. Which laboratory finding indicates the highest risk complication?
- Blood glucose of 210 mg/dL
- Sodium of 139 mEq/L
- Phosphorus of 1.2 mg/dL (Correct answer)
- Albumin of 3.0 g/dL
Correct answer: Phosphorus of 1.2 mg/dL
Severe hypophosphatemia in a patient receiving TPN suggests refeeding syndrome, a potentially fatal metabolic complication.
Question 2: A nurse is caring for a patient who is 6 hours post-coronary angiography via the right femoral artery. Which assessment finding is most concerning?
- Heart rate of 78 beats/min
- A large expanding hematoma at the puncture site (Correct answer)
- Patient complaint of needing to void
- Blood pressure of 122/76 mmHg
Correct answer: A large expanding hematoma at the puncture site
An expanding hematoma at the femoral access site indicates active bleeding and potential vascular injury requiring immediate intervention.
Question 3: The nurse is caring for a patient with a serum sodium of 118 mEq/L receiving a hypertonic saline infusion. The nurse should monitor the patient most carefully for which complication?
- Hypokalemia
- Osmotic demyelination syndrome (Correct answer)
- Fluid volume deficit
- Metabolic alkalosis
Correct answer: Osmotic demyelination syndrome
Correcting hyponatremia too rapidly with hypertonic saline can cause osmotic demyelination syndrome, leading to permanent neurological damage.
Question 4: A nurse caring for a patient in Buck's traction discovers that the weights are resting on the floor. What should the nurse do?
- Leave the weights in place to reduce patient discomfort
- Reposition the patient so the weights hang freely (Correct answer)
- Remove the traction and notify the orthopedic surgeon
- Document the finding and reassess in one hour
Correct answer: Reposition the patient so the weights hang freely
Traction is only effective when weights hang freely; resting weights eliminate the therapeutic pull needed to maintain alignment.
Question 5: A nurse notes that a patient's urine output has been 20 mL/hour for the past 3 hours. What is the nurse's priority action?
- Document the finding and continue monitoring
- Encourage the patient to increase oral fluid intake
- Notify the provider and assess for contributing factors (Correct answer)
- Insert a urinary catheter to improve accuracy
Correct answer: Notify the provider and assess for contributing factors
Urine output below 30 mL/hour indicates oliguria and potential renal hypoperfusion, which requires provider notification and prompt assessment.
Question 6: A patient on mechanical ventilation has a sudden rise in peak airway pressure. What is the nurse's first action?
- Increase the FiO2 setting on the ventilator
- Suction the patient's endotracheal tube
- Manually ventilate the patient with a bag-valve mask (Correct answer)
- Adjust the tidal volume setting on the ventilator
Correct answer: Manually ventilate the patient with a bag-valve mask
Manual ventilation with a bag-valve mask ensures the patient receives adequate breaths while the cause of high peak pressure is investigated.
Question 7: A nurse is preparing to administer a unit of packed red blood cells. Which action is essential just before starting the infusion?
- Warm the blood product in a microwave for 30 seconds
- Prime the tubing with dextrose 5% in water (D5W)
- Have a second nurse verify the blood product with the patient's identification band (Correct answer)
- Administer diphenhydramine prophylactically to all patients
Correct answer: Have a second nurse verify the blood product with the patient's identification band
Two-nurse verification of blood product compatibility with the patient's identification is mandatory to prevent a potentially fatal transfusion error.
RN Registered Nurse: Reduction of Risk Potential 5
A nurse is assessing a patient who has been receiving total parenteral nutrition (TPN) for 5 days.
Which laboratory finding indicates the highest risk complication?