Select All That Apply Practice Test #3: Reduction of Risk Potential

Correct answers (A, C, E):
A. The client worked as a welder and once had a metal fragment removed from the eye.
C. The client has a pacemaker placed 6 years ago.
E. The client wears an insulin pump on the abdomen.

Rationale: The MRI magnet can move metal objects, heat them, or stop a device from working. A history of metal in the eye, common in welders and metal workers, must be reported; the MRI team may order an X-ray to screen the orbits first (A). Pacemakers and defibrillators must be reported because only some are labeled MR-conditional, and those still need special settings and monitoring (C). Insulin pumps and continuous glucose monitors are usually removed before the scan, following the device maker's instructions and a plan for the client's insulin (E). Option B is wrong because a shellfish allergy does not predict a reaction to MRI (gadolinium) contrast; a past reaction to contrast itself is what matters. Option D is wrong because ordinary dental fillings are not a safety risk in MRI, although they can affect the picture near the mouth. Each facility uses its own MRI screening form and safety staff make the final decision.

Correct answers (A, B, D):
A. Pain that keeps getting worse and is not relieved by the prescribed opioid.
B. Severe pain when the nurse gently straightens the client's fingers.
D. New numbness and tingling in the fingers.

Rationale: These findings point to acute compartment syndrome, where rising pressure inside a muscle compartment cuts off blood flow to muscles and nerves. Early signs include pain out of proportion to the injury that is not relieved by the prescribed pain medicine (A), pain when the muscles are passively stretched (B), and new numbness or tingling (D). It is an emergency: the nurse reports it right away, keeps the limb at heart level rather than raised above it, and follows the provider's orders, which may include loosening or splitting the cast. Pale skin, a weak or absent pulse and paralysis are late signs; the nurse does not wait for them. Options C and E are wrong because warm pink fingers with brisk refill and full movement are normal findings.

Correct answers (B, C, D, E):
B. Stay with the client and have another staff member notify the surgeon.
C. Cover the wound with sterile dressings moistened with sterile normal saline.
D. Place the client in low Fowler's position with the knees bent.
E. Keep the client NPO.

Rationale: Evisceration, when organs come out through a separated incision, is a surgical emergency. The nurse stays with the client, keeps them calm, and sends someone to call the surgeon or rapid response (B). The organs are covered with sterile dressings or towels moistened with sterile normal saline so the tissue does not dry out (C). Low Fowler's position with the knees bent lowers tension on the abdominal muscles (D). The client is kept NPO because a return to surgery is likely (E). The nurse also checks vital signs for signs of shock. Option A is wrong because the nurse never tries to put the organs back; this can injure the bowel and add infection.

Correct answers (B, D, E):
B. Help the client walk as soon as the surgeon allows.
D. Apply sequential compression devices as prescribed while the client is in bed.
E. Teach the client to do ankle pumps and foot circles every hour while awake.

Rationale: After orthopedic surgery, slow blood flow, vein injury and changes in clotting raise the risk of deep vein thrombosis. Early walking as soon as the surgeon allows is one of the best ways to keep blood moving (B). Sequential compression devices squeeze the legs to push venous blood back toward the heart and are used as prescribed (D). Ankle pumps and foot circles use the calf muscles to help venous return (E). Many clients also receive an anticoagulant as prescribed. Option A is wrong because a sore calf can be a sign of a clot, and massage could dislodge it; the nurse assesses and reports it instead. Option C is wrong because a pillow under the knees presses on the veins behind the knee and slows blood flow.

Correct answers (A, C, D):
A. An unexplained rise in end-tidal carbon dioxide.
C. Stiffness of the jaw muscles or the whole body.
D. A heart rate that rises with no clear cause.

Rationale: Malignant hyperthermia is an inherited reaction to certain anesthesia gases and succinylcholine that sends the muscles into a high-energy state. One of the earliest signs is a rise in end-tidal carbon dioxide that is not explained by the ventilator settings (A). Muscle stiffness, often starting with the jaw (masseter rigidity), is another early sign (C). Tachycardia without another cause is also early (D). Option B is wrong because the heart rate goes up, not down. Option E is wrong because the high fever often comes later, so the team does not wait for it. Treatment follows the facility's malignant hyperthermia protocol: stop the trigger drugs, give dantrolene as prescribed, cool the client and treat high potassium and acidosis. Ask every surgical client about a personal or family history of problems with anesthesia.

Correct answers (A, C, D, E):
A. Stop the transfusion.
C. Keep the IV line open with normal saline using new tubing.
D. Notify the provider and the blood bank, and follow policy for returning the blood bag and tubing.
E. Stay with the client and check vital signs.

Rationale: Chills, fever and back pain early in a transfusion can mean an acute hemolytic reaction, which can be life threatening. The nurse stops the transfusion right away (A) and keeps IV access with normal saline through new tubing, so no more blood from the old tubing enters the vein (C). The provider and blood bank are notified, and the bag, tubing and any blood or urine samples are handled as the facility policy says (D). The nurse stays with the client and monitors vital signs, breathing and urine output (E). Option B is wrong because slowing the rate still gives the client more of the blood that may be causing the reaction. The nurse also rechecks the client's ID and the blood product label.

Correct answers (A, B, D):
A. Check that coagulation results and the platelet count have been reviewed before the procedure.
B. Teach the client to breathe out and hold the breath while the needle is inserted.
D. After the procedure, position the client on the right side.

Rationale: The liver has a rich blood supply, so bleeding is the main risk. Clotting tests and the platelet count are checked before the procedure, and abnormal results are reported to the provider (A). The client breathes out fully and holds the breath during needle insertion; this keeps the diaphragm and liver still and high, away from the lung (B). Afterward, the client lies on the right side, often with a small pillow or towel under the lower ribs, to press on the puncture site for the time the facility protocol sets (D). Vital signs are checked often to watch for bleeding. Option C is wrong because the client stays on bed rest after the procedure as ordered. Option E is wrong because a deep breath in pushes the liver down and raises the risk of puncturing the lung.

Correct answers (B, C, D):
B. Help the client curl on one side with knees drawn toward the chest and chin tucked.
C. After the procedure, check the puncture site for drainage or swelling.
D. Report new numbness or tingling in the legs or a severe headache.

Rationale: Curling on the side with the knees to the chest and the chin tucked (or sitting and leaning forward over a table) widens the spaces between the lower lumbar vertebrae so the needle can enter the spinal canal (B). Afterward, the nurse checks the site for leaking fluid, bleeding or swelling (C). New numbness, tingling or weakness in the legs, or a severe headache, can mean bleeding near the spine or a spinal fluid leak and are reported (D). A headache that gets worse when sitting or standing is a known complication and is also reported. Option A is wrong because lying on the stomach with the neck extended does not open the spaces between the vertebrae. Option E is wrong because fluids are usually encouraged unless the client has a fluid restriction.

Correct answers (A, B, C, E):
A. Drink only clear liquids the day before, as your instructions say.
B. Avoid red and purple drinks and gelatin.
C. Plan for a responsible adult to drive you home.
E. Report severe belly pain, fever or heavy bleeding from the rectum after the test.

Rationale: A clean colon lets the provider see the lining well. The client follows the clear liquid diet and bowel prep exactly as their instructions say, because timing differs between preparations (A). Red and purple drinks are avoided because the color can look like blood in the colon (B). Sedation affects judgment and reaction time, so a responsible adult drives the client home (C). Severe belly pain, fever, or heavy rectal bleeding after the test can mean a perforation or bleeding and are reported right away (E). A small amount of gas or cramping is common. Option D is wrong because the client should not drive for the time the facility sets after sedation, even if they feel awake. The provider also tells the client which home medicines, such as blood thinners or diabetes medicines, to hold or change before the test.

Correct answers (B, C, E):
B. Remove jewelry, including piercings, as the facility policy requires.
C. Confirm when the client last ate or drank, and compare it with the anesthesia instructions.
E. Check that the client's ID band and allergy band match the chart.

Rationale: Jewelry and piercings are removed as policy requires because they can cause burns from electrosurgical equipment, pressure injury, or swelling problems (B). The nurse confirms the last time the client ate or drank and compares it with the anesthesia instructions, because food or fluid in the stomach raises the risk of aspiration; fasting times vary with the type of food and the client (C). The ID band and allergy band are checked against the chart as part of client safety (E). Option A is wrong because shaving with a razor makes tiny cuts that raise the infection risk; if hair must be removed, clippers are used close to the time of surgery. Option D is wrong because the provider and anesthesia team decide which medicines are taken on the morning of surgery, usually with a small sip of water, and which are held.