NCLEX-RN Reduction of Risk Potential Summary

After a catheter is placed through the femoral artery (in the groin), a clot or bleeding can block blood flow to the leg. The nurse checks the leg below the site often: pulses, color, warmth, and feeling. A cool, pale foot with a weak pulse suggests the artery is blocked. This is an emergency and must be reported right away.

Wrong choices

• "Lying flat with leg straight": this is the expected position after a femoral procedure to protect the puncture site.
• "Mild soreness": expected at a puncture site. Increasing swelling or bleeding would be a concern.
• "Urinating more": expected. The contrast dye acts like a mild diuretic, and clients are often given fluids to flush it out.

A pulmonary embolism (PE) is a blood clot that travels to the lungs, often from a leg vein. Surgery, especially hip and leg surgery, and lying in bed raise the risk. Classic signs come on suddenly: shortness of breath, sharp chest pain on breathing in, fast heart rate, anxiety, and low oxygen. This is an emergency. The nurse stays with the client, raises the head of the bed, gives oxygen, and calls for help.

Wrong choices

• "Atelectasis": collapse of small air sacs. It is common after surgery but usually develops more gradually, with decreased breath sounds and sometimes a low-grade fever, not sudden sharp pain.
• "Wound dehiscence": the incision opens. It does not cause chest pain and shortness of breath.
• "Paralytic ileus": the bowel stops moving. It causes a swollen belly and no bowel sounds, not chest pain.

Compare each result with its reference range. Only the potassium is abnormal, and it is high. A potassium of 6.2 mEq/L (hyperkalemia) can cause dangerous heart rhythms and even cardiac arrest. The nurse reports it right away and often places the client on a heart monitor as ordered.

The nurse may also ask whether the sample could be falsely high (for example, from blood cells breaking during the draw), but this is decided with the provider. It is not a reason to delay reporting.

Wrong choices

• "Sodium 138": within the range given.
• "Hemoglobin 12.6": within the range given.
• "Random glucose 118": within the range given.

RNs keep tasks that need nursing judgment: assessing, teaching, evaluating, and caring for unstable clients. UAPs can do routine, predictable tasks for stable clients, such as measuring vital signs, helping with bathing, walking, and recording intake and output. The RN still reviews the results.

Wrong choices

• "Assessing the incision": assessment, especially a new problem, belongs to the RN.
• "Teaching incentive spirometer use": teaching is an RN responsibility. (A UAP can remind a client to use it after the RN has taught.)
• "Evaluating pain medicine": evaluation of a treatment's effect needs nursing judgment.

Look at the trend, not just one set of numbers. The heart rate keeps going up while the blood pressure keeps going down, and the breathing gets faster. The client is also restless with cool, clammy skin. This pattern means the body is losing blood volume and trying to make up for it (hypovolemic shock). After surgery, the most likely cause is bleeding, which may be inside the body even if the dressing looks dry.

The nurse checks the dressing and drains, stays with the client, and notifies the provider (rapid response) right away.

Wrong choices

• "Uncontrolled pain": pain can raise the heart rate and blood pressure. It would not make the blood pressure keep falling.
• "Normal recovery": vital signs should become more stable, not worse, as anesthesia wears off.
• "Fluid overload": would cause high blood pressure, crackles in the lungs, and swelling, not falling blood pressure with cool skin.

IV contrast dye is removed from the body by the kidneys, and it can harm kidneys that are already weak. So before the test, the nurse checks kidney function, usually the serum creatinine (often with the eGFR, a calculation based on creatinine). A high creatinine means the kidneys are not filtering well, and the provider may change the plan, give extra fluids, or hold certain medicines such as metformin.

The nurse also asks about past reactions to contrast dye.

Wrong choices

• "Hemoglobin": useful in many situations, but it does not show whether the kidneys can handle contrast.
• "Serum calcium": not related to contrast safety.
• "Serum amylase": a pancreas test, not related to contrast safety.

When the incision opens and organs come through it, this is called evisceration. It is an emergency. The nurse stays with the client and covers the organs with sterile gauze moistened with sterile normal saline. Moist dressings keep the tissue from drying out and dying. The nurse then calls for help, places the client with the head slightly raised and knees bent to reduce strain, and monitors for shock. Surgery is usually needed.

Wrong choices

• "Push the bowel back": this can injure the bowel and bring in infection. Only the surgeon replaces organs.
• "Dry sterile dressing": a dry dressing sticks to the tissue and dries it out.
• "Walk to the bathroom": moving and straining can push more organs out.

An incentive spirometer helps prevent atelectasis (collapse of the small air sacs) and pneumonia after surgery. The client seals the lips around the mouthpiece and breathes IN slowly and deeply, then holds the breath for a few seconds (often 3 to 5) to keep the air sacs open. It is usually done about 10 times every hour while awake.

Wrong choices

• "Blow out as hard as I can": the device is used by breathing in, not out.
• "Once a day": not enough. It is used many times a day, usually every hour while awake.
• "Breathe quickly": fast breaths do not open the deep air sacs. The goal is slow, deep breaths.

In a thoracentesis, a needle is placed between the ribs to drain fluid around the lung. A key risk is that the needle nicks the lung and air leaks into the chest, causing a pneumothorax (collapsed lung). Warning signs are new or worse shortness of breath, sharp chest pain, fast breathing, falling oxygen levels, and decreased or absent breath sounds on the procedure side. The nurse reports this right away; a chest X-ray is often ordered.

Wrong choices

• "Small, dry bandage": expected. A wet or bloody bandage would need attention.
• "Mild soreness": expected after a needle procedure.
• "Oxygen saturation 96%": a normal value for most adults.

The parathyroid glands sit behind the thyroid and control blood calcium. They can be bruised or removed by accident during thyroid surgery. Then calcium drops (hypocalcemia). Early signs are tingling or numbness around the mouth and in the fingers and toes, and muscle cramps. Without treatment, it can lead to muscle spasms, including in the throat, and seizures. The nurse reports it promptly; calcium is usually checked and replaced.

Wrong choices

• "Slightly hoarse voice": common for a few days because of the breathing tube and swelling. Worsening hoarseness or noisy breathing would be a concern.
• "Sore throat": expected after surgery and the breathing tube.
• "Small amount of drainage": expected. Large or increasing drainage would need attention.