Reduction of Risk Potential Master Quiz

Drill 25 #1:

A client presents with elevations in triiodothyronine (T₃) and thyroxine (T₄) and with normal thyroid-stimulating hormone (TSH) levels. Which is the nurse's priority intervention?

• Monitor the apical pulse.

• Administer propranolol.

• Check for Trousseau's sign.

• Administer levothyroxine.

Answer explanation

Rationale: The client's laboratory findings suggest that the client is experiencing hyperthyroidism. The increased metabolic rate can cause an increase in the client's heart rate, and the client should be monitored for the development of dysrhythmias. Placing the client on a telemetry monitor might also be an appropriate precaution. Synthroid is given for hypothyroidism. Propranolol is a beta-blocker often used to lower sympathetic nervous system activity in hyperthyroidism. Hyperthyroidism can cause a mild to moderate elevation in serum calcium levels but Trousseau's sign is indicative of hypocalcemia, not hypercalcemia.

Drill 25 #2:

The nurse is reviewing the plan of care for a client with a sacral, stage III pressure ulcer who is prescribed continuous negative-pressure wound therapy (NPWT). For which finding should the nurse notify the health care provider (HCP) immediately?

• The wound has extensive tunneling.

• The client is receiving apixaban.

• The client is receiving enteral nutrition.

• The client is incontinent of stool.

Answer explanation

Rationale: Apixaban is an anticoagulant (a direct factor Xa inhibitor) used to reduce the risk of stroke and systemic embolism in clients with atrial fibrillation. Anticoagulant therapy is a contraindication for NPWT due to the increased risk of bleeding in the wound. The other findings do not contraindicate the use of NPWT.

Drill 25 #3:

The nurse is caring for a client who received thrombolytic therapy for an acute myocardial infarction (MI). Which information is most important for the nurse to communicate to the health care provider (HCP)?

• An increase in troponin levels from baseline

• A large bruise at the client's IV insertion site

• No change in the client's reported level of chest pain

• A decrease in ST-segment elevation on the ECG

Answer explanation

Rationale: Continued chest pain suggests myocardial ischemia and that the thrombolytic therapy is not effective. Other coronary interventions may be needed, such as a stent. Bruising is a possible side effect of thrombolytic therapy and should be monitored, but it is not more important to report than unrelieved chest pain. The decrease of the ST-segment elevation indicates that perfusion is returning to the injured myocardium. An increase in troponin levels is expected with reperfusion and is related to the release of cardiac biomarkers into the circulation as the blocked vessel reopens.

Drill 25 #4:

When taking a client's blood pressure (BP) after a parathyroidectomy, the nurse notes that the client's hand has gone into flexion contractions. Which laboratory result does the nurse correlate with this condition?

• Serum calcium level of 6.9 mg/dL

• Serum sodium level of 122 mEq/L

• Serum potassium level of 5.8 mEq/L

• Serum potassium level of 2.9 mEq/L

Answer explanation

Rationale: The parathyroid glands maintain calcium and phosphate balance through the release of parathyroid hormone (PTH) that acts directly on the kidney, causing increased kidney reabsorption of calcium and increased phosphorus excretion. After surgical removal of the parathyroid glands, a hypocalcemic crisis can occur due to the absence of PTH. Hypocalcemia destabilizes excitable membranes and can lead to muscle twitches, spasms and tetany. The flexion contractions that occur while measuring BP (Trousseau's sign) indicate hypocalcemia, not the other electrolyte imbalances, which include hypokalemia, hyperkalemia and hyponatremia.

Drill 25 #5:

While caring for a client after lumbar spine surgery, which action can the nurse on the ortho-spine unit delegate to the unlicensed assistive person (UAP)?

• Ask about pain control with the patient-controlled analgesia (PCA)

• Check the client's ability to plantar and dorsiflex the foot

• Determine the client's readiness to ambulate

• Log roll the client from side to side every two hours

Answer explanation

Rationale: Repositioning a client is included in the training of UAPs. UAPs working on a specialty unit, such as ortho-spine, will be familiar with how to maintain alignment for a postoperative spinal surgery client. Evaluating the effectiveness of pain management, assessing neurologic function such as plantar and dorsiflexion, and evaluating a client's readiness to ambulate after surgery require higher-level nursing education and scope of practice and, therefore, cannot be delegated to UAPs.

Drill 25 #6:

A client has a new order for an open magnetic resonance imaging (MRI) scan without contrast to evaluate for osteomyelitis. Which information indicates that the nurse should consult with the health care provider (HCP) before scheduling the MRI?

• The client has a history of claustrophobia

• The client has an allergy to shellfish

• The client has a pacemaker

• The client wears prescription glasses

Answer explanation

Rationale: Clients with a pacemaker, an internal device made of metal, cannot have an MRI scan done because of the force exerted by the magnetic field on metal objects. An open MRI scan is unlikely to cause claustrophobia. The client will be instructed to remove the glasses before the MRI scan, but this does not require consultation with the HCP. Because contrast medium will not be used, a shellfish allergy is not a contraindication to the MRI scan.

Drill 25 #7:

The home health nurse is working with a client who was recently discharged from the hospital and is diagnosed with orthostatic hypotension. Which client statement indicates that additional teaching is needed?

• I should drink no more than six glasses of water per day.

• I should take my time getting out of bed in the morning.

• I will purchase a home blood pressure machine.

• I should check my blood pressure before taking my morning medications.

Answer explanation

Rationale: Orthostatic hypotension occurs when there is a precipitous decrease in blood pressure upon a change in position, such as sitting or standing. For this reason, clients must stay adequately hydrated and should assure adequate time for acclimation when changing position. Restricting fluid intake to less than six glasses of water per day may exacerbate orthostatic hypotension and is an incorrect statement that requires additional teaching. Clients should monitor vital signs prior to taking any medications that can lower blood pressure to avoid worsening orthostatic hypotension.

Drill 25 #8:

The nurse is caring for a child who has just returned from surgery following a tonsillectomy and adenoidectomy. Which action by the nurse is most appropriate?

• Place the child in a supine position

• Observe swallowing patterns

• Allow the child to drink through a straw

• Offer ice cream every two hours

Answer explanation

Rationale: Tonsillectomies and adenoidectomies are the removal of a client's tonsils and adenoids. These procedures are routinely performed when a client suffers from frequent bouts of tonsillitis or resistant forms of tonsillitis. Complications of these procedures include bleeding, infection, and dehydration. In the post-operative area, clients should be positioned at a 45° angle. This position allows the client to maintain a patent airway. It also can prevent aspiration in the event that the client begins to hemorrhage. One manifestation of bleeding includes frequent swallowing. It is imperative that the nurse monitors the client's swallowing patterns. In the post-operative area, clients should drink from a glass, not a straw. Straws could disrupt the suture lines from the procedure. After a tonsillectomy, clients should gradually introduce fluids back into their diet. The literature suggests starting with clear fluids, not full liquids. Starting full liquids may cause nausea, vomiting and frequent coughing.

Drill 25 #9:

The nurse is taking a health history from the parents of a child who is admitted for Reye's syndrome. Which recent illness would the nurse identify as a significant risk of developing Reye's syndrome?

• Rubeola

• Meningitis

• Influenza

• Hepatitis

Answer explanation

Rationale: Varicella (chickenpox) and influenza are viral illnesses that have been identified as risks for the development of Reye's syndrome. It is important for nurses to educate parents to not use aspirin in children (birth to 19 years of age). The use of aspirin in the presence of viral infections can increase the risk of Reye's syndrome for children.

Drill 25 #10:

The nurse in an intensive care unit is reviewing the laboratory results for several clients. Which laboratory result indicates that the client has a partially compensated metabolic acidosis?

• PaCO₂ of 30 mmHg

• HCO3 of 28 mEq/L

• pH of 7.48

• Chloride of 100 mEq/L

Answer explanation

Rationale: With metabolic acidosis, the nurse should expect to see a low pH (less than 7.35) and a low HCO₃ (less than 22 mEq/L). Compensation means that the body is trying to get the pH back to a normal range of 7.35 to 7.45. A pure metabolic acidosis will elicit a compensatory response by the lungs in form of a decrease in PaCO₂ (normal range is 35 to 45 mm Hg). Therefore, the PaCO₂ level of 30 mm Hg indicates a partially compensated metabolic acidosis. A pH of 7.48 indicates an alkalosis and the chloride level does not pertain to the acid-base imbalance or compensation