EDAPT NCLEX Readiness: Reduction of Risk Potential –
High-Yield Exam Questions Verified Provided with A+
Graded Rationales Latest Updated 2026
Click to specify the nursing actions that will help reduce the risk of complications for this client
and the actions that would produce greater complications for this client. Select one option per
row.
Reduces Risk of Complications:
▸ Assist the client with ambulation using a walker.
▸ Consult with a speech therapist about the use of adding thickening agents to water and other
oral liquids.
▸ Place absorbent pads on top of the fitted sheet in the bed.
▸ Assist the client in making position changes in the bed or chair at least every 2 hours.
Increases Risk of Complications:
▸ Stand on the client's left side when assisting with ambulation.
▸ Request a prescription for an indwelling urinary catheter.
▸ Place a donut cushion under the client's bottom when seated in the wheelchair.
The nurse develops a teaching plan for a client having an upcoming total knee arthroplasty.
What information should the nurse include in the preoperative teaching to promote health and
reduce the risk of complications? Select all that apply.
▸ "The provider will prescribe a stool softener for you to take while you are taking pain
medication."
▸ "It is important for you to perform deep breathing exercises and cough several times an hour
when you're awake for a few weeks after the surgery."
▸ "Make sure to cleanse your knee with the 2% chlorohexidine wipes the night before surgery
and the morning of surgery."
The nurse cares for a client in the intensive care unit who is on a mechanical ventilator, has a
triple-lumen central venous access device (CVAD), and a urinary catheter. For each treatment
device, identify the nursing actions to include in the plan of care to reduce the risk of
complications. Select one or more answers related to nursing care for each device.
Mechanical Ventilator:
1. Routinely clean the client's mouth with chlorhexidine solutions.
2. Elevate the head of the bed at least 30 degrees.
,3. Turn the client every 2 hours.
4. Pause sedation at least once per 24 hours.
Central Venous Access Device (CVAD):
2. Use a 10 mL syringe when flushing or giving medications.
3. Assess for compatibility before putting more than one agent in a line together.
4. Place a mask on the client and wear one as the nurse during dressing changes.
Urinary Catheter:
2. Maintain bag below level of pelvis.
3. Perform peri-care every shift and after bowel movements.
4. Empty the drainage bag every few hours or when 2/3 full.
Click to specify the steps of the procedure that the observing nurse should question and those
that indicate the procedure nurse completed the prescribed procedure correctly.
Observing Nurse Should Question:
▸ Opened all supplies using clean gloves
▸ Donned clean gloves to cleanse the area with chlorhexidine swab sticks before switching to
sterile gloves for insertion
▸ Secured the catheter to the client's inner thigh after insertion as the urine drains into the
collection container
Procedure Nurse Performed Correctly:
▸ Cleaned the perineal area with soap and water prior to the procedure
▸ Removed the catheter from the bladder after collecting the amount needed
▸ Labeled the urine specimen container with the client's initials, date of birth, date and time of
the collection, route used for specimen collection, and nurse's initials
The nurse is assessing a stable client with fluid imbalance concerns. The nurse reviews the
electronic health record and finds this information:
What actions should the nurse take first? Select all that apply.
▸ Verify the cuff size.
▸ Recheck the client's blood pressure.
The nurse admits a client into the triage area and reviews the client's vital signs.
Based on the client's trends in vital signs, the nurse is initially the most concerned with the
, __________ and should anticipate a prescription for the priority intervention, which is to
__________.
▸ Oxygen saturation
▸ Administer oxygen
The nurse admits an older adult client to the medical-surgical unit with a suspected urinary tract
infection. The hospital policy is for two nurses to complete an admission skin assessment.
Highlight the sections in the nursing note that put the client at an increased risk for skin
breakdown.
▸ Diabetes
▸ Neuropathy
▸ Peripheral vascular disease
▸ Cool to touch in distal extremities
▸ Non-blanchable redness noted above the client's sacrum
▸ Bruise noted on right lower calf
▸ She does not feel it
▸ Urinary incontinence
A client is admitted to a long-term care facility due to inability to remain independent with
activities of daily living. The client had a fall 6 weeks ago and, while no bones were fractured,
the client experienced pain and discomfort that limited mobility after the fall. The client's adult
child is present at the start of the admission and reports the client has "been in bed for most of
the last month." Which questions should the nurse ask to assess the client's risk of
complications associated with prolonged immobility? Select all that apply.
▸ "Have you had any thoughts about harming yourself in the last 6 weeks?"
▸ "Do you have any new areas of redness on your bottom or heels?"
▸ "Tell me more about your sleeping habits. How are you sleeping at night?"
▸ "Is it more difficult to move your joints now than it was before your injury?"
▸ "What has your energy level been like over the last 6 weeks?"
The nurse admits a client into the emergency department who ran into a tree while skiing in the
mountains. The client sustained an open fracture to the left lower leg and has bruises
developing in many locations on the body. The first responders required 15 minutes to reach
the client due to the location of the crash. Complete the following sentences using the drop-
down options.
The nurse recognizes that the risk of __________ is the priority concern because of the
High-Yield Exam Questions Verified Provided with A+
Graded Rationales Latest Updated 2026
Click to specify the nursing actions that will help reduce the risk of complications for this client
and the actions that would produce greater complications for this client. Select one option per
row.
Reduces Risk of Complications:
▸ Assist the client with ambulation using a walker.
▸ Consult with a speech therapist about the use of adding thickening agents to water and other
oral liquids.
▸ Place absorbent pads on top of the fitted sheet in the bed.
▸ Assist the client in making position changes in the bed or chair at least every 2 hours.
Increases Risk of Complications:
▸ Stand on the client's left side when assisting with ambulation.
▸ Request a prescription for an indwelling urinary catheter.
▸ Place a donut cushion under the client's bottom when seated in the wheelchair.
The nurse develops a teaching plan for a client having an upcoming total knee arthroplasty.
What information should the nurse include in the preoperative teaching to promote health and
reduce the risk of complications? Select all that apply.
▸ "The provider will prescribe a stool softener for you to take while you are taking pain
medication."
▸ "It is important for you to perform deep breathing exercises and cough several times an hour
when you're awake for a few weeks after the surgery."
▸ "Make sure to cleanse your knee with the 2% chlorohexidine wipes the night before surgery
and the morning of surgery."
The nurse cares for a client in the intensive care unit who is on a mechanical ventilator, has a
triple-lumen central venous access device (CVAD), and a urinary catheter. For each treatment
device, identify the nursing actions to include in the plan of care to reduce the risk of
complications. Select one or more answers related to nursing care for each device.
Mechanical Ventilator:
1. Routinely clean the client's mouth with chlorhexidine solutions.
2. Elevate the head of the bed at least 30 degrees.
,3. Turn the client every 2 hours.
4. Pause sedation at least once per 24 hours.
Central Venous Access Device (CVAD):
2. Use a 10 mL syringe when flushing or giving medications.
3. Assess for compatibility before putting more than one agent in a line together.
4. Place a mask on the client and wear one as the nurse during dressing changes.
Urinary Catheter:
2. Maintain bag below level of pelvis.
3. Perform peri-care every shift and after bowel movements.
4. Empty the drainage bag every few hours or when 2/3 full.
Click to specify the steps of the procedure that the observing nurse should question and those
that indicate the procedure nurse completed the prescribed procedure correctly.
Observing Nurse Should Question:
▸ Opened all supplies using clean gloves
▸ Donned clean gloves to cleanse the area with chlorhexidine swab sticks before switching to
sterile gloves for insertion
▸ Secured the catheter to the client's inner thigh after insertion as the urine drains into the
collection container
Procedure Nurse Performed Correctly:
▸ Cleaned the perineal area with soap and water prior to the procedure
▸ Removed the catheter from the bladder after collecting the amount needed
▸ Labeled the urine specimen container with the client's initials, date of birth, date and time of
the collection, route used for specimen collection, and nurse's initials
The nurse is assessing a stable client with fluid imbalance concerns. The nurse reviews the
electronic health record and finds this information:
What actions should the nurse take first? Select all that apply.
▸ Verify the cuff size.
▸ Recheck the client's blood pressure.
The nurse admits a client into the triage area and reviews the client's vital signs.
Based on the client's trends in vital signs, the nurse is initially the most concerned with the
, __________ and should anticipate a prescription for the priority intervention, which is to
__________.
▸ Oxygen saturation
▸ Administer oxygen
The nurse admits an older adult client to the medical-surgical unit with a suspected urinary tract
infection. The hospital policy is for two nurses to complete an admission skin assessment.
Highlight the sections in the nursing note that put the client at an increased risk for skin
breakdown.
▸ Diabetes
▸ Neuropathy
▸ Peripheral vascular disease
▸ Cool to touch in distal extremities
▸ Non-blanchable redness noted above the client's sacrum
▸ Bruise noted on right lower calf
▸ She does not feel it
▸ Urinary incontinence
A client is admitted to a long-term care facility due to inability to remain independent with
activities of daily living. The client had a fall 6 weeks ago and, while no bones were fractured,
the client experienced pain and discomfort that limited mobility after the fall. The client's adult
child is present at the start of the admission and reports the client has "been in bed for most of
the last month." Which questions should the nurse ask to assess the client's risk of
complications associated with prolonged immobility? Select all that apply.
▸ "Have you had any thoughts about harming yourself in the last 6 weeks?"
▸ "Do you have any new areas of redness on your bottom or heels?"
▸ "Tell me more about your sleeping habits. How are you sleeping at night?"
▸ "Is it more difficult to move your joints now than it was before your injury?"
▸ "What has your energy level been like over the last 6 weeks?"
The nurse admits a client into the emergency department who ran into a tree while skiing in the
mountains. The client sustained an open fracture to the left lower leg and has bruises
developing in many locations on the body. The first responders required 15 minutes to reach
the client due to the location of the crash. Complete the following sentences using the drop-
down options.
The nurse recognizes that the risk of __________ is the priority concern because of the
