Reduction of Risk Potential

Note: These questions include ones similar to alternative format questions as seen on the NCLEX-RN exam.

The nurse is assessing the vital signs of a 6-month-old infant. Which of these respiratory rates is cause for concern?

A patient with severe renal artery stenosis is under nursing care. Which of the patient’s vital signs would the nurse most likely find to be abnormal as a result of this condition?

A critical patient with multiple traumas has a Swan-Ganz catheter in place for invasive hemodynamic monitoring. Which of these values requires the brief inflation of a balloon at the distal port of the catheter?

A nurse is caring for a 77-year-old, hearing-impaired, client immediately post-operative total hip arthroplasty. The nurse starts discussing post-operative care with the client. The client becomes increasingly agitated with the nurse. Which intervention should the nurse perform?

A nurse is caring for a patient who must give a sputum culture. The patient has consented for the procedure and the nurse is giving him the proper instructions. Which of these are the proper instructions the nurse should give to the patient for this test?

When preparing for a clean catch urine specimen, what will the nurse need to do differently for female versus male patients?

A 44-year-old female patient has recently had her annual physical exam. She calls to inquire about the results of her lipid testing. Her results are as follows: total cholesterol 235 mg/dL, triglycerides 300 mg/dL, LDL 155 mg/dL, and HDL 42 mg/dL. Which of these is the correct way for the nurse to present the results to this patient?

The nurse is caring for an acutely ill patient in the ER with a suspected myocardial infarction (MI). His symptoms began about 3 hours ago. The nurse is the first to review his cardiac lab values. Based on his suspected diagnosis, which of these cardiac enzymes would the nurse expect to see elevated?

A 20-year-old female presents to the urgent care with complaints of fever, headache, vomiting, and a rash that has progressed over the past 24 hours. During her physical exam, she has positive Kernig and Brudzinski tests. A lumbar puncture is ordered. Which of these statements is the correct rationale for ordering this test that the nurse should explain to the patient?

A patient has an arterial blood gas (ABG) drawn. The results are as follows: pH 7.3, PCO2 46, and HCO3 29. Based on these findings, what condition does this patient have?

The nurse is working in an oncology clinic caring for a patient currently undergoing treatment for colorectal cancer. Which of these tumor markers would most likely be used to monitor the patient’s disease?

Which of these patients would a nurse determine is not at a significant risk for aspiration?

Which of the following are intrinsic risk factors for skin breakdown? Select all that apply.

A. poor nutritional status
B. shearing/mechanical forces
C. urinary and/or fecal incontinence
D. bony prominences
E. wedge or positioning device use

A nurse is caring for a patient who recently had surgery to set a fracture and now has his extremity casted. Which of these nursing examinations is not typically utilized to assess for compartment syndrome?

Which of these procedures and/or conditions is improperly paired with the preferred patient positioning?

A 55-year-old female is 22 hours post-op from a total thyroidectomy. The nurse is reviewing the patient’s most recent laboratory studies and preparing her for discharge. The nurse notes no abnormalities other than a slightly low calcium level. Which of these is the correct course of action for the nurse to take?

A nurse is caring for a patient who has orders for assessment of cranial nerves I-VII. Which of these techniques will the nurse use for her assessment?

Which of these is not considered to be an important risk factor for delayed and/or impaired wound healing?

A nurse is educating the parents of a newborn that has been diagnosed with phenylketonuria (PKU). Which of these statements indicates that the nurse needs to do further education on the nature and management of this disorder?

A 67-year-old postmenopausal female presents for a general health screening. She has not had a physical in the past 5 years. She states she is in good health and takes no medications. She is concerned about having osteoporosis. She asks if she can have a test to see if she has it. Which of these is the correct response from the nurse to this patient?