NACE Reduction of Risk Potential 4 — Questions and Answers
Question 1: A nurse reviews a client's medication list and notes they are taking warfarin. Which laboratory value is most critical to monitor to reduce risk of bleeding complications?
- Partial thromboplastin time (PTT)
- International Normalized Ratio (INR) (Correct answer)
- Platelet count
- Bleeding time
Correct answer: International Normalized Ratio (INR)
INR is the standard test used to monitor warfarin therapy and guide dosing to prevent hemorrhage.
Question 2: A postoperative client reports sudden onset of chest pain and shortness of breath on day 2 after hip replacement surgery. What is the nurse's priority action?
- Administer prescribed analgesic
- Notify the physician immediately (Correct answer)
- Encourage deep breathing exercises
- Reposition the client to the left side
Correct answer: Notify the physician immediately
Sudden chest pain and dyspnea after orthopedic surgery are classic signs of pulmonary embolism, requiring immediate physician notification.
Question 3: Which nursing intervention best reduces the risk of aspiration in a client receiving continuous enteral tube feedings?
- Flush the tube with 30 mL water every 8 hours
- Keep the head of bed elevated at 30–45 degrees (Correct answer)
- Check residual volumes once per shift
- Administer feedings at room temperature
Correct answer: Keep the head of bed elevated at 30–45 degrees
Elevating the head of the bed 30–45 degrees reduces gastroesophageal reflux and the risk of aspiration pneumonia.
Question 4: A client with chronic kidney disease has a serum potassium of 6.2 mEq/L. Which assessment finding requires the nurse's most immediate action?
- Blood pressure of 148/90 mmHg
- Irregular cardiac rhythm on telemetry (Correct answer)
- Mild bilateral ankle edema
- Urine output of 25 mL/hour
Correct answer: Irregular cardiac rhythm on telemetry
Hyperkalemia causes cardiac dysrhythmias, which can be life-threatening and require immediate intervention.
Question 5: A nurse is caring for a client receiving a blood transfusion who develops hives, itching, and mild urticaria 15 minutes after the infusion begins. What is the priority nursing action?
- Stop the transfusion and notify the physician
- Slow the infusion rate and monitor closely
- Administer diphenhydramine and continue the transfusion
- Stop the transfusion, keep the IV open with normal saline, and notify the physician (Correct answer)
Correct answer: Stop the transfusion, keep the IV open with normal saline, and notify the physician
An allergic transfusion reaction requires stopping the transfusion, maintaining IV access with normal saline, and notifying the physician to determine further management.
Question 6: A nurse prepares to insert a urinary catheter. Which action is most important in reducing the risk of catheter-associated urinary tract infection (CAUTI)?
- Using the smallest catheter size appropriate
- Maintaining a closed drainage system (Correct answer)
- Irrigating the catheter with normal saline daily
- Taping the catheter to the inner thigh
Correct answer: Maintaining a closed drainage system
Maintaining a sterile, closed drainage system is the single most effective measure for preventing CAUTI.
Question 7: A client who underwent general anesthesia 4 hours ago has a temperature of 39.2°C (102.6°F), tachycardia, and muscle rigidity. Which condition does the nurse suspect?
- Neuroleptic malignant syndrome
- Malignant hyperthermia (Correct answer)
- Septic shock
- Thyroid storm
Correct answer: Malignant hyperthermia
Malignant hyperthermia is a life-threatening reaction to certain anesthetic agents characterized by hyperthermia, tachycardia, and severe muscle rigidity.
NACE Reduction of Risk Potential 4
A nurse reviews a client's medication list and notes they are taking warfarin.
Which laboratory value is most critical to monitor to reduce risk of bleeding complications?