Answers and Rationale for NCLEX RN Review of Reduction of Risk Potential

These answers are one of the NCLEX prep samples for Reduction of Risk Potential. Click here to view the questions.

1. B. The elevated creatinine level suggests impaired renal function. Assessing intake and output will provide data related to renal function. The other assessments are not indicative of renal function.

2. D. Hyperextension brings the pharynx into alignment with the trachea and allows the scope to be inserted without trauma.

3. B. Palpating pulses distal to the insertion site is important to evaluate for thrombophlebitis and vessel occlusion. They should be bilateral and strong.

4. A. Urinary tract infections in the elderly often present as urinary incontinence that develops suddenly. Renal failure (1) and fluid volume excess (3) typically are characterized by oliguria. Dementia (4) develops slowly and is manifested by disordered thinking and behavior.

5. D. The most important safety measure is to tape a hemostat nearby to use in case of an air leak. Chest tubes should be checked periodically, but not necessarily every 2 hours (2). The client should be in semi-Fowler’s position to increase lung expansion.

6. C. There is an increased incidence of hemorrhaging with the external cannula. Hemorrhage results from the cannula becoming disconnected. One advantage of the external cannula is that it is painless to use. Surgery is required to establish the internal fistula and it should be allowed to heal for several weeks before being utilized.

7. A. The rope/pulley and weight system is arranged so that fracture fragments are in the desired approximate position for healing. The client’s position should always rest in line with the traction pull. The line of pull must never be interfered with by changing the position of a pulley and extension bar.

8. A. Russell’s traction is a type of skin traction that incorporates a sling under the knee that is connected by a rope to an overhead bar pulley. It is frequently used to treat femoral shaft fractures in the adolescent.

9. D. Increased pulse and pallor are symptoms associated with shock. A compromised venous return may occur if there is a mediastinal shift as a result of excessive fluid removal. Usually no more than 1 L of fluid is removed at one time to prevent this from occurring.

10. B. The collection bag must be able to fill easily; therefore, it needs to be distended. The bag must be vented with a filter so that urine can be drained from the chamber. The tube must not be allowed to coil or become kinked above the level of the bladder. The collection bag is positioned below the level of the bladder to allow for continuous urine drainage and prevent urine backflow into the bladder. In order to prevent reflux of urine, the tubing must be of sufficient length, usually 5 feet.

11. B. Because more weight can be applied with skeletal traction, it can be used to reduce fractures and maintain alignment. It is not used commonly in the elderly because of prolonged immobilization. It is not preferred for children because some displacement of fracture fragments is desirable to prevent growth disturbance. Frequently, clients have more mobility than they do with skin traction, because balanced suspension is often incorporated with skeletal traction.

12. C. Diabetes insipidus is an antidiuretic deficiency and may occur following brain surgery or head injury. It also occurs in young adults resulting from damage to the posterior lobe of the pituitary gland. Severe polyuria occurs when there is an inability to concentrate urine. These are not symptoms of types 1 and 2 diabetes (2, 3) or Addison’s disease (4) (which is adrenocorticol hypofunction).

13. D. Preventing cerebral trauma during the convulsion is a priority activity. Placing some form of padding under the head will protect the skull and brain from injury. Inserting a mouth gag (1) and restraining the limbs (3) are unsafe interventions. The nurse would not leave a seizing person to go and obtain equipment (4).

14. D. The respiratory system can become occluded if the balloon slips and moves up the esophagus, putting pressure on the trachea. This would result in respiratory distress and should be assessed frequently. Scissors should be kept at the bedside to cut the tube if distress occurs. This is a safety intervention.

15. A. Putting pressure over the vessels in the neck may be lifesaving because a severe blood loss can occur rapidly, leading to shock and death. The surgeon would be notified as soon as possible.

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