15 free questions from the CinnaRN reduction of risk potential bank (324 in the app). Tap an answer to check it. The rationale opens right away.
During fluid resuscitation of a client with major burns, the nurse monitors which finding as the best indicator that resuscitation is adequate?
Answer: A. Urine output of 30 to 50 mL/hr
Urine output is the most reliable bedside indicator of end-organ perfusion during burn resuscitation. A target of about 30 to 50 mL/hr (0.5 mL/kg/hr) in adults reflects adequate renal perfusion and guides titration of fluids. Blood pressure can be unreliable because of peripheral edema and vasoconstriction; thirst and edema do not quantify perfusion.
A client receiving heparin develops a platelet count that has dropped from 250,000 to 90,000/mm3 over several days, with a new clot in the leg. The nurse suspects which complication?
Answer: A. Heparin-induced thrombocytopenia
Heparin-induced thrombocytopenia (HIT) is an immune reaction that causes a falling platelet count and, paradoxically, new arterial or venous thromboses. Management requires stopping all heparin and starting a non-heparin anticoagulant.
A client on digoxin has a serum digoxin level of 3.2 ng/mL with nausea, confusion, and visual disturbances. Which is the antidote for severe digoxin toxicity?
Answer: B. Digoxin immune Fab
Digoxin immune Fab (digoxin-specific antibody fragments) is the antidote for life-threatening digoxin toxicity. The therapeutic digoxin range is 0.5 to 2 ng/mL, so 3.2 ng/mL is toxic. Yellow-green vision changes are classic.
A client is receiving 0.45% sodium chloride, a hypotonic solution. Which client should the nurse identify as having a CONTRAINDICATION to this fluid?
Answer: A. A client with increased intracranial pressure
Hypotonic fluids shift water into cells and can worsen cerebral edema, so they are contraindicated in clients with increased intracranial pressure or head injury. They are used cautiously for cellular dehydration but are dangerous with rising ICP.
A client arrives in the emergency department with sudden-onset right-sided weakness and slurred speech that began 90 minutes ago. Which action should the nurse anticipate as the highest priority?
Answer: B. Obtain a noncontrast CT scan of the head
For an acute ischemic stroke within the treatment window, rapid noncontrast CT of the head is the priority to rule out hemorrhage before thrombolytic therapy can be considered. Imaging must precede tPA.
During a nonstress test, the nurse observes two accelerations of the fetal heart rate of at least 15 beats per minute above baseline, each lasting at least 15 seconds, within a 20-minute period. How should the nurse interpret this result?
Answer: A. Reactive and reassuring
A reactive nonstress test, defined by at least two qualifying accelerations in 20 minutes, indicates adequate fetal oxygenation and is a reassuring finding. A nonreactive result lacks sufficient accelerations. A positive contraction stress test and late decelerations are different, concerning findings.
A client is receiving warfarin after orthopedic surgery. Which laboratory result should the nurse review to evaluate the therapeutic effect of this drug?
Answer: B. International normalized ratio (INR)
Warfarin therapy is monitored with the prothrombin time reported as the INR. Activated partial thromboplastin time monitors heparin, platelet count screens for thrombocytopenia, and hemoglobin reflects blood loss but none of these gauge warfarin's effect.
A client recovering from a partial gastrectomy reports dizziness, sweating, palpitations, and diarrhea about 20 minutes after eating. The nurse recognizes these as signs of which problem?
Answer: B. Dumping syndrome
Early dumping syndrome occurs 15 to 30 minutes after eating when hyperosmolar food rapidly enters the small intestine, drawing fluid into the bowel and causing dizziness, diaphoresis, palpitations, cramping, and diarrhea. Management includes small frequent meals, lying down after eating, limiting fluids with meals, and a low-carbohydrate, higher-protein diet. These symptoms are not typical of a wound infection, a recurrent ulcer, or simple anxiety.
A client recovering from a myocardial infarction develops multifocal PVCs that increase in frequency. Why does the nurse consider this finding significant?
Answer: A. They may progress to ventricular tachycardia or fibrillation
Frequent, multifocal, or increasing PVCs in the setting of acute myocardial ischemia indicate ventricular irritability and can deteriorate into ventricular tachycardia or ventricular fibrillation. The nurse should notify the provider and monitor closely. PVCs are not a normal expected finding here, are not benign in this context, and do not indicate adequate perfusion.
A nurse is preparing IV digoxin for an infant. Which serum value should be reviewed because it increases the risk of digoxin toxicity?
Answer: A. Low potassium level
Hypokalemia (low potassium) potentiates digoxin and increases the risk of toxicity and dysrhythmias. Reviewing the potassium level before administration is an essential safety step.
A child receiving digoxin for heart failure begins vomiting and reports nausea, and the heart rate has slowed. The nurse recognizes these as early signs of which problem?
Answer: B. Digoxin toxicity
Nausea, vomiting, anorexia, bradycardia, and visual changes are classic early signs of digoxin toxicity. These findings are not consistent with hypokalemia alone, a viral infection, or normal medication effects, and require evaluation of the digoxin level.
A client's INR on warfarin is 1.4 (subtherapeutic for atrial fibrillation). The nurse recognizes the client is at increased risk for:
Answer: B. Clot formation and stroke
A subtherapeutic INR means inadequate anticoagulation and increased clot/stroke risk in atrial fibrillation — the dose is usually increased per protocol and rechecked.
A client at 10 weeks gestation has severe nausea and vomiting, weight loss of 6 percent of prepregnancy weight, and ketonuria. Which condition does the nurse suspect?
Answer: B. Hyperemesis gravidarum
Hyperemesis gravidarum is persistent, excessive vomiting causing weight loss greater than 5 percent of prepregnancy weight, dehydration, ketonuria, and electrolyte imbalance. Normal morning sickness does not cause significant weight loss; the other options are unrelated complications.
A newborn's total serum bilirubin is rising rapidly on day 2 of life. The nurse anticipates which finding pattern in pathologic versus physiologic jaundice?
Answer: B. A rapid rise suggesting a possible hemolytic process
Pathologic jaundice is suggested by onset within the first 24 hours, a total bilirubin rising faster than about 5 mg/dL per day, levels above the age-specific phototherapy threshold, or jaundice persisting beyond 1-2 weeks. A rapid rise on day 2 with high levels suggests a hemolytic process such as ABO or Rh incompatibility.
A client at 22 weeks gestation has a blood pressure of 148/96 mm Hg on two readings 4 hours apart, with no proteinuria and no other symptoms. How should the nurse classify this finding?
Answer: B. Gestational hypertension
New-onset blood pressure of 140/90 mm Hg or higher after 20 weeks gestation without proteinuria or other systemic signs is gestational hypertension. Preeclampsia requires proteinuria or end-organ signs; chronic hypertension is present before 20 weeks; eclampsia includes seizures.
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