NCSBN - National Council of State Boards of Nursing Reduction of Risk Potential Questions and Answers

Question 1

A nurse is reviewing the laboratory results of a client with a potassium level of 2.9 mEq/L. Which of the following assessments is the nurse's priority?

Accepted Answer

Assessing the client's cardiac rhythm

Answer

Monitoring for Chvostek's sign

Answer

Checking for pitting edema in the extremities

Answer

Measuring the client's abdominal girth

Question 2

A nurse is caring for a client who has just undergone a lumbar puncture. To reduce the risk of a post-dural puncture headache, which intervention should the nurse implement?

Accepted Answer

Instruct the client to remain in a flat or supine position.

Answer

Encourage immediate ambulation to promote circulation.

Answer

Restrict oral fluid intake for the first 4 hours.

Answer

Administer a prophylactic sedative medication.

Question 3

A nurse is preparing a client for a computed tomography (CT) scan of the abdomen with intravenous contrast. Which of the following findings in the client's record requires the most immediate intervention by the nurse?

Accepted Answer

A serum creatinine level of 2.5 mg/dL.

Answer

A documented history of claustrophobia.

Answer

A reported allergy to shellfish.

Answer

The client is currently prescribed metformin.

Question 4

A nurse is assessing a client who is three days postoperative from a total knee arthroplasty. The client suddenly reports feeling anxious, short of breath, and has a sense of impending doom. Which additional finding would most strongly suggest the development of a pulmonary embolism?

Accepted Answer

An acute onset of pleuritic chest pain and tachypnea.

Answer

A productive cough with thick, green sputum.

Answer

Bradycardia with a blood pressure of 90/50 mmHg.

Answer

Swelling, warmth, and redness in the calf.

Question 5

A nurse is initiating a transfusion of packed red blood cells (PRBCs) for a client. Which of the following actions is most critical for the nurse to perform within the first 15 minutes of the infusion?

Accepted Answer

Remain with the client and monitor vital signs.

Answer

Increase the infusion rate to the prescribed maximum.

Answer

Document the client's baseline intake and output.

Answer

Administer an antihistamine to prevent a reaction.

Question 6

A nurse is caring for a client with a new short-leg cast for a fractured tibia. The client reports severe pain in the affected leg that is not relieved by opioid analgesics. The nurse notes the client's toes are pale and cool. What is the nurse's priority action?

Accepted Answer

Notify the healthcare provider immediately.

Answer

Elevate the casted leg on two pillows.

Answer

Apply a new ice pack over the area of pain.

Answer

Administer the next scheduled dose of pain medication.

A nurse is reviewing the laboratory results of a client with a potassium level of 2.9 mEq/L.Which of the following assessments is the nurse's priority?

A nurse is reviewing the laboratory results of a client with a potassium level of 2.9 mEq/L.
Which of the following assessments is the nurse's priority?