NACE Reduction of Risk Potential 2 — Questions and Answers
Question 1: A nurse is preparing a patient for a lumbar puncture. Which position should the patient be placed in?
- Prone with a pillow under the abdomen
- Lateral recumbent with knees drawn to chest and chin tucked (Correct answer)
- Supine with legs elevated
- Sitting upright leaning forward over a bedside table
Correct answer: Lateral recumbent with knees drawn to chest and chin tucked
The lateral recumbent (fetal) position with knees drawn to the chest and chin tucked maximally opens the intervertebral spaces for needle insertion during lumbar puncture.
For a lumbar puncture, the preferred position is lateral recumbent (side-lying) with knees drawn to the chest, chin tucked, and back arched (C-shape). This position flexes the spine, widening the intervertebral spaces between L3-L4 or L4-L5.
Question 2: Which assessment finding in a patient with a new hip fracture fixation requires immediate nursing intervention?
- Pain rated 4/10 with movement
- Ability to wiggle toes on the affected side
- Foot on the affected side is cool, pale, and pulses are absent (Correct answer)
- Mild swelling at the surgical site
Correct answer: Foot on the affected side is cool, pale, and pulses are absent
Absent pulses, pallor, and coolness in the affected extremity indicate compromised neurovascular status, possibly from compartment syndrome or vascular injury requiring emergent intervention.
The 6 Ps of compartment syndrome or vascular compromise are: Pain (disproportionate), Pallor, Pulselessness, Paresthesia, Paralysis, and Poikilothermia. Absent pulses with pallor and coolness suggest arterial compromise requiring emergency evaluation. Fasciotomy must be performed within 6 hours to prevent permanent damage.
Question 3: A patient is scheduled for an MRI. Which item must the nurse ensure is removed before the procedure?
- Hearing aids (Correct answer)
- Cotton hospital gown
- Plastic identification bracelet
- Non-metallic hair tie
Correct answer: Hearing aids
Hearing aids contain metal components and batteries that can be damaged by or become projectiles in the strong magnetic field of an MRI, and they must be removed before the scan.
MRI uses a powerful magnetic field. All ferromagnetic objects must be removed to prevent projectile injuries, device malfunction, tissue burns, and image artifacts. Items to remove include hearing aids, watches, jewelry, hairpins, glasses, and dentures with metal.
Question 4: A nurse is monitoring a patient who had a cardiac catheterization via the femoral artery 2 hours ago. Which finding requires immediate action?
- Small bruise at the insertion site
- Patient reports mild soreness at the groin
- Expanding hematoma at the femoral access site (Correct answer)
- Blood pressure of 128/78 mmHg
Correct answer: Expanding hematoma at the femoral access site
An expanding hematoma at the femoral access site indicates ongoing bleeding that requires immediate intervention including direct pressure and physician notification.
Post-cardiac catheterization care focuses on monitoring the access site and distal circulation. An expanding hematoma indicates ongoing arterial bleeding and requires immediate firm pressure, notification of the cardiologist, and frequent vital sign monitoring.
Question 5: A patient with diabetes mellitus has a fasting blood glucose of 52 mg/dL and is conscious. What is the nurse's priority intervention?
- Administer IV dextrose 50%
- Give 15 grams of a fast-acting carbohydrate orally (Correct answer)
- Administer glucagon intramuscularly
- Recheck the glucose level in 30 minutes
Correct answer: Give 15 grams of a fast-acting carbohydrate orally
For a conscious patient with hypoglycemia, the 15-15 rule applies: give 15 grams of fast-acting carbohydrate, wait 15 minutes, and recheck the blood glucose.
Hypoglycemia in conscious patients follows the 15-15 rule: administer 15 grams of fast-acting carbohydrate (4 oz juice, 4 glucose tablets), wait 15 minutes, recheck glucose, and repeat if still below 70 mg/dL. IV D50 and glucagon are for unconscious patients.
Question 6: A nurse is caring for a patient with a central venous catheter. Which complication should the nurse monitor for during and immediately after insertion?
- Phlebitis
- Pneumothorax (Correct answer)
- Peripheral neuropathy
- Cellulitis
Correct answer: Pneumothorax
Pneumothorax is an acute complication of central venous catheter insertion, particularly with subclavian or internal jugular approaches, caused by accidental lung puncture.
Central venous catheter insertion, particularly via subclavian or internal jugular veins, carries a 1-6% risk of pneumothorax due to lung apex proximity. A post-insertion chest X-ray is mandatory to confirm catheter tip position and rule out pneumothorax.
NACE Reduction of Risk Potential 2
A nurse is preparing a patient for a lumbar puncture.
Which position should the patient be placed in?