NCLEX Reduction of Risk Potential Questions Answers [Rationale]

Last Updated on July 4, 2024

NCLEX Reduction of Risk Potential Questions Answers [Rationale]. Free practice tests for the NCLEX-RN and NCLEX-PN exams. You can download the P Reduction of Risk Potential test in PDF format.

Physiological Integrity – Reduction of Risk Potential questions compose 9 to 15 percent of the exam.

These questions ask about creating a healthcare environment that lowers clients’ risk of complications or health problems due to treatments, conditions, or procedures. Be alert for diagnostic tests and their potential for complications, therapeutic procedures, complications from surgical procedures, laboratory values, the potential for alterations in body systems, and changes and abnormalities in vital signs.

NCLEX Reduction of Risk Potential Questions Answers

Q1. A nurse is monitoring a client who has just returned from a colonoscopy. Which finding requires immediate intervention?

(A) Mild abdominal discomfort
(B) Passing small amounts of gas
(C) Rectal bleeding
(D) Feeling of fullness

View Answer

Answer: (C)
Rationale: Rectal bleeding after a colonoscopy can indicate a perforation or other serious complication and requires immediate intervention.

Q2. A client is scheduled for a cardiac catheterization. Which pre-procedure instruction is most important?

(A) “You may eat a light breakfast before the procedure.”
(B) “Report any history of allergies, especially to shellfish or iodine.”
(C) “Take your usual dose of anticoagulants before the procedure.”
(D) “You will be able to drive yourself home after the procedure.”

View Answer

Answer: (B)
Rationale: Allergies to shellfish or iodine may indicate a risk for allergic reactions to the contrast dye used in the procedure.

Q3. A nurse is caring for a client who has undergone a lumbar puncture. Which position should the nurse encourage the client to maintain after the procedure to reduce the risk of complications?

(A) Supine with the head of the bed elevated
(B) Sitting up straight
(C) Prone
(D) Lying flat

View Answer

Answer: (D)
Rationale: Lying flat helps prevent post-lumbar puncture headaches by allowing the cerebrospinal fluid to redistribute evenly.

Q4. A client with a history of deep vein thrombosis (DVT) is being discharged. Which instruction should the nurse include to prevent recurrence?

(A) “Avoid wearing compression stockings.”
(B) “Take frequent walks throughout the day.”
(C) “Stay in bed as much as possible.”
(D) “Apply heat to your legs regularly.”

View Answer

Answer: (B)
Rationale: Taking frequent walks promotes circulation and helps prevent the formation of new blood clots.

Q5. A nurse is assessing a client who has just undergone thoracentesis. Which finding requires immediate action?

(A) Increased respiratory rate
(B) Diminished breath sounds on the affected side
(C) Mild discomfort at the puncture site
(D) Small amount of serous drainage

View Answer

Answer: (B)
Rationale: Diminished breath sounds on the affected side may indicate a pneumothorax, a serious complication requiring immediate intervention.

Q6. A client is receiving a blood transfusion and begins to exhibit signs of a transfusion reaction. What is the nurse’s first action?

(A) Slow the infusion rate
(B) Notify the healthcare provider
(C) Stop the transfusion immediately
(D) Administer antihistamines

View Answer

Answer: (C)
Rationale: Stopping the transfusion immediately is the priority to prevent further exposure to the potentially harmful blood product.

Q7. A nurse is caring for a client with a chest tube. Which finding indicates a potential complication?

(A) Continuous bubbling in the water seal chamber
(B) Intermittent bubbling in the suction control chamber
(C) Drainage of 50 mL over the past hour
(D) Tidaling in the water seal chamber

View Answer

Answer: (A)
Rationale: Continuous bubbling in the water seal chamber may indicate an air leak in the chest tube system and requires immediate assessment and intervention.

Q8. A nurse is monitoring a client with an epidural catheter for pain management. Which assessment finding requires immediate intervention?

(A) Mild itching at the insertion site
(B) Decreased sensation in the lower extremities
(C) Urinary retention
(D) Respiratory rate of 8 breaths per minute

View Answer

Answer: (D)
Rationale: A respiratory rate of 8 breaths per minute indicates respiratory depression, a serious complication of epidural anesthesia that requires immediate intervention.

Q9. A nurse is caring for a client post-appendectomy. Which sign indicates a potential complication of the procedure?

(A) Moderate incisional pain
(B) Low-grade fever
(C) Abdominal distension
(D) Bowel sounds present in all quadrants

View Answer

Answer: (C)
Rationale: Abdominal distension may indicate a postoperative complication such as paralytic ileus or peritonitis and requires immediate evaluation.

Q10. A client is scheduled for a barium swallow study. Which instruction should the nurse provide to the client post-procedure to reduce the risk of complications?

(A) “Drink plenty of fluids to help eliminate the barium.”
(B) “Avoid eating for 24 hours after the procedure.”
(C) “Remain on bed rest for the rest of the day.”
(D) “Expect severe abdominal pain and cramping.”

View Answer

Answer: (A)
Rationale: Drinking plenty of fluids helps eliminate the barium from the body and reduces the risk of constipation.

Q11. A nurse is caring for a client who has undergone a thyroidectomy. Which assessment finding indicates a complication that requires immediate intervention?

(A) Hoarseness
(B) Difficulty swallowing
(C) Tingling around the mouth and fingers
(D) Mild neck pain

View Answer

Answer: (C)
Rationale: Tingling around the mouth and fingers may indicate hypocalcemia due to accidental removal of or damage to the parathyroid glands, requiring immediate intervention.

Q12. A client with diabetes is scheduled for a fasting blood glucose test. Which instruction is most important for the nurse to give?

(A) “Take your usual dose of insulin the night before the test.”
(B) “Eat a light meal two hours before the test.”
(C) “Avoid all food and drink except water for 8-12 hours before the test.”
(D) “You can have black coffee the morning of the test.”

View Answer

Answer: (C)
Rationale: The client should avoid all food and drink except water for 8-12 hours before a fasting blood glucose test to ensure accurate results.

Q13. A nurse is caring for a client who is receiving chemotherapy. Which laboratory value should the nurse monitor closely to assess for a potential complication?

(A) Hemoglobin
(B) Platelet count
(C) Blood glucose
(D) Serum calcium

View Answer

Answer: (B)
Rationale: Platelet count should be monitored closely because chemotherapy can cause thrombocytopenia, increasing the risk of bleeding.

Q14. A client is receiving IV antibiotics for an infection. The nurse notes redness, swelling, and warmth at the IV site. What is the nurse’s best action?

(A) Slow the infusion rate
(B) Apply a warm compress
(C) Discontinue the IV and restart at a different site
(D) Flush the IV line with normal saline

View Answer

Answer: (C)
Rationale: Redness, swelling, and warmth at the IV site indicate phlebitis or infiltration. The IV should be discontinued and restarted at a different site.

Q15. A nurse is caring for a client post-cholecystectomy. Which assessment finding indicates a complication that requires immediate attention?

(A) Yellow-green drainage from the surgical site
(B) Low-grade fever
(C) Mild nausea
(D) Pain at the incision site

View Answer

Answer: (A)
Rationale: Yellow-green drainage from the surgical site may indicate a bile leak or infection, requiring immediate attention.

Q16. A nurse is monitoring a client after a liver biopsy. Which position should the nurse place the client in immediately after the procedure?

(A) Supine
(B) Prone
(C) Right side-lying
(D) Left side-lying

View Answer

Answer: (C)
Rationale: Placing the client in the right side-lying position applies pressure to the biopsy site and helps prevent bleeding.

Q17. A client with a history of heart failure is being discharged with a new prescription for furosemide. Which instruction is most important to prevent complications?

(A) “Weigh yourself daily and report a weight gain of more than 2 pounds in a day.”
(B) “Increase your fluid intake to stay hydrated.”
(C) “Avoid foods high in potassium.”
(D) “Take the medication at bedtime.”

View Answer

Answer: (A)
Rationale: Daily weight monitoring helps detect fluid retention, a potential complication of heart failure, and the use of diuretics.

Q18. A nurse is caring for a client with a nasogastric tube to low intermittent suction. Which electrolyte imbalance is the client most at risk for?

(A) Hyperkalemia
(B) Hypokalemia
(C) Hypercalcemia
(D) Hyponatremia

View Answer

Answer: (B)
Rationale: Clients with nasogastric tubes to low intermittent suction are at risk for hypokalemia due to the loss of gastric fluids rich in potassium.

Q19. A nurse is monitoring a client who has just returned from the operating room after an abdominal surgery. Which finding requires immediate intervention?

(A) Absent bowel sounds
(B) Heart rate of 110 beats per minute
(C) Blood pressure of 130/80 mmHg
(D) Pain level of 4/10

View Answer

Answer: (B)
Rationale: A heart rate of 110 beats per minute may indicate hypovolemia or pain, requiring immediate intervention to determine and address the cause.

Q20. A client with chronic kidney disease is scheduled for hemodialysis. Which laboratory value is most important to monitor?

(A) Hemoglobin
(B) Blood urea nitrogen (BUN)
(C) Serum potassium
(D) Serum calcium

View Answer

Answer: (C)
Rationale: Monitoring serum potassium is crucial for clients with chronic kidney disease undergoing hemodialysis due to the risk of hyperkalemia.

Q21. A nurse is caring for a client with a tracheostomy. Which assessment finding indicates a complication that requires immediate attention?

(A) Clear secretions
(B) Difficulty breathing
(C) Occasional coughing
(D) Slight redness around the stoma

View Answer

Answer: (B)
Rationale: Difficulty breathing may indicate an obstruction or dislodgement of the tracheostomy tube, requiring immediate attention.

Q22. A client is receiving enteral nutrition through a gastrostomy tube. Which finding indicates a potential complication?

(A) Increased gastric residual volumes
(B) Soft, formed stools
(C) Weight gain
(D) Active bowel sounds

View Answer

Answer: (A)
Rationale: Increased gastric residual volumes can indicate delayed gastric emptying and a risk for aspiration, requiring further evaluation.

Q23. A nurse is monitoring a client who has just received contrast dye for a CT scan. Which assessment finding requires immediate intervention?

(A) Mild nausea
(B) Feeling of warmth
(C) Difficulty breathing
(D) Metallic taste in the mouth

View Answer

Answer: (C)
Rationale: Difficulty breathing may indicate an allergic reaction to the contrast dye, requiring immediate intervention.

Q24. A nurse is caring for a client with hyperthyroidism who is scheduled for a thyroidectomy. Which preoperative instruction is most important to reduce the risk of complications?

(A) “Avoid all foods high in iodine.”
(B) “Report any signs of infection immediately.”
(C) “Take all medications as prescribed, including beta-blockers.”
(D) “Avoid all physical activity before surgery.”

View Answer

Answer: (C)
Rationale: Taking all medications as prescribed, including beta-blockers, helps control symptoms of hyperthyroidism and reduces the risk of complications during surgery.

Q25. A nurse is caring for a client post-hip replacement surgery. Which intervention is most important to prevent dislocation of the prosthesis?

(A) Maintaining the client in a high Fowler’s position
(B) Encouraging the client to cross their legs to increase circulation
(C) Keeping the affected leg in adduction
(D) Using an abduction pillow while the client is in bed

View Answer

Answer: (D)
Rationale: Using an abduction pillow helps maintain proper alignment and prevents dislocation of the hip prosthesis.

See also:

Free NCLEX Practice Test with Study Guide [UPDATED 2024-25]

Safe and Effective Care Environment

Health Promotion and Maintenance

Health Promotion and Maintenance Questions

Psychosocial Integrity