Nursing Acceleration Challenge Exam I PN-RN Reduction of Risk Potential Questions and Answers 1 — Questions and Answers
Question 1: A nurse is reviewing the laboratory results for a client receiving warfarin therapy. The client's International Normalized Ratio (INR) is 4.5. Which action should the nurse take first?
- Administer the next scheduled dose of warfarin.
- Prepare to administer protamine sulfate.
- Hold the next dose of warfarin and notify the healthcare provider. (Correct answer)
- Document the finding as within the therapeutic range.
Correct answer: Hold the next dose of warfarin and notify the healthcare provider.
An INR of 4.5 is critically high, placing the client at a significant risk for bleeding. The therapeutic range for most conditions is 2.0 to 3.0. The nurse's first priority is to hold the medication to prevent further elevation of the INR and immediately notify the healthcare provider, who will provide orders, which may include administering the antidote, Vitamin K.
Question 2: A nurse is preparing to assist with a thoracentesis for a client with a large pleural effusion. To reduce the risk of puncturing the lung, which position should the nurse assist the client into?
- Seated on the edge of the bed, leaning forward over a bedside table. (Correct answer)
- Lying flat in a supine position.
- In a side-lying position with the affected side up.
- In Trendelenburg position.
Correct answer: Seated on the edge of the bed, leaning forward over a bedside table.
The upright position, with the client seated and leaning forward over a bedside table, widens the intercostal spaces and allows fluid to accumulate at the base of the lung due to gravity. This positioning makes needle insertion easier and safer, moving the lung tissue up and away from the insertion site, thereby reducing the risk of a pneumothorax.
Question 3: A nurse is creating a plan of care for a client newly diagnosed with an acute deep vein thrombosis (DVT) in the left leg. Which of the following nursing interventions should be included in the plan?
- Massaging the affected calf gently to reduce pain.
- Applying sequential compression devices (SCDs) to both legs.
- Encouraging active range-of-motion exercises for the affected leg.
- Elevating the affected extremity while the client is in bed. (Correct answer)
Correct answer: Elevating the affected extremity while the client is in bed.
For a client with an acute DVT, elevating the affected leg is recommended to promote venous return by gravity, which helps decrease edema and pain. Massaging the leg, applying SCDs to the affected limb, and performing active range-of-motion exercises are contraindicated as they can dislodge the thrombus, potentially leading to a life-threatening pulmonary embolism.
Question 4: A client preparing for a colonoscopy is consuming the prescribed polyethylene glycol solution and reports feeling nauseated and bloated. The client states, "I don't think I can drink any more of this." Which nursing response is most appropriate to reduce the risk of an incomplete bowel preparation?
- "It's important to finish the prep; try to drink the rest as quickly as possible."
- "You can take a short break for about 30-60 minutes, then resume drinking the solution at a slower pace." (Correct answer)
- "I will bring you some solid food to help settle your stomach."
- "Stop drinking the solution immediately and we will notify the doctor to cancel the procedure."
Correct answer: "You can take a short break for about 30-60 minutes, then resume drinking the solution at a slower pace."
Nausea and bloating are common side effects of bowel preparation solutions. The most effective strategy is to temporarily pause for 30-60 minutes, allow the symptoms to subside, and then resume drinking at a slower rate. This approach increases the likelihood of completing the prep, which is essential for adequate visualization during the colonoscopy, thus reducing the risk of a failed or repeated procedure.
Question 5: The nurse is assessing a client who is 72 hours postoperative following a total hip arthroplasty. Which assessment finding is most indicative of a potential pulmonary embolism and requires immediate notification of the provider?
- Pain at the surgical site rated 4 out of 10.
- Scant serosanguineous drainage on the surgical dressing.
- Sudden onset of shortness of breath and pleuritic chest pain. (Correct answer)
- Temperature of 99.8°F (37.7°C) and diminished breath sounds in the lung bases.
Correct answer: Sudden onset of shortness of breath and pleuritic chest pain.
Sudden onset of dyspnea and pleuritic chest pain are hallmark signs of a pulmonary embolism (PE), a life-threatening complication of immobility and major surgery, especially orthopedic surgery. This finding constitutes a medical emergency requiring immediate intervention. While diminished breath sounds and a low-grade fever can indicate atelectasis, it is not as acutely life-threatening as a PE.
Question 6: A nurse is caring for a client on prolonged bed rest. To reduce the client's risk of developing renal calculi, which intervention is the highest priority?
- Ensuring a fluid intake of 2,500 to 3,000 mL per day. (Correct answer)
- Providing a low-calcium diet.
- Administering prophylactic antibiotics.
- Assisting the client to a high-Fowler's position for all meals.
Correct answer: Ensuring a fluid intake of 2,500 to 3,000 mL per day.
Immobility leads to urinary stasis and bone demineralization, which increases the concentration of calcium and other minerals in the urine, predisposing the client to stone formation. The most effective and highest priority nursing intervention to prevent renal calculi is to ensure adequate hydration (2-3 L/day). A high fluid intake keeps urine dilute and flowing, which prevents mineral precipitation.
Nursing Acceleration Challenge Exam I PN-RN Reduction of Risk Potential Questions and Answers 1
A nurse is reviewing the laboratory results for a client receiving warfarin therapy.
The client's International Normalized Ratio (INR) is 4.5.
Which action should the nurse take first?