KAPLAN REDUCTION OF RISK POTENTIAL
ASSESSMENT QUESTIONS AND CORRECT ANSWERS
(VERIFIED ANSWERS) PLUS RATIONALES 2026 Q&A
|LATEST EXAM UPDATE 2026/2027 EXAM with
Questions and Answers/Plus a Rationale Updated
2026 A+/Instant Download PDF
EXAM COVERAGE
1. Potential for Alterations in Body Systems
2. Therapeutic Procedures
3. Laboratory Values
4. System Specific Assessments
5. Diagnostic Tests
6. Changes in Vital Signs
7. Potential for Complications of Diagnostic Tests/Treatments/Procedures
1. A nurse is caring for a client who is 4 hours post-operative following a total knee arthroplasty.
The client reports sudden sharp chest pain and exhibits tachycardia (120 bpm) and tachypnea
(28/min). Which action is the priority?
A. Administer a PRN dose of hydromorphone for pain
B. Elevate the head of the bed and administer oxygen
C. Check the surgical site for signs of hematoma
D. Increase the rate of IV fluids to support the blood pressure
, CORRECT ANSWER : B
Rationale: The client's symptoms (sudden chest pain, tachycardia, tachypnea) indicate a
potential pulmonary embolism. Elevating the head of the bed and initiating oxygen addresses the
priority of airway and oxygenation before any other intervention.
2. A client receiving a packed red blood cell transfusion develops flank pain, fever, and chills.
What is the nurse's immediate action?
A. Slow the transfusion rate and monitor vital signs
B. Stop the transfusion immediately and maintain the line with normal saline
C. Administer diphenhydramine as a prophylactic measure
D. Notify the blood bank to re-verify the cross-match
CORRECT ANSWER : B
Rationale: Flank pain and fever during a transfusion are hallmarks of an acute hemolytic
reaction. The transfusion must be stopped immediately to minimize the volume of incompatible
blood administered, and the IV line should be kept patent with saline.
3. A nurse is reviewing the lab results of a client with heart failure. Which result is most concerning
in the context of digoxin therapy?
A. Serum sodium 138 mEq/L
B. Serum potassium 3.1 mEq/L
C. Blood urea nitrogen 18 mg/dL
D. Serum calcium 9.2 mg/dL
CORRECT ANSWER : B
Rationale: Hypokalemia significantly increases the sensitivity of the myocardium to digoxin,
predisposing the client to lethal arrhythmias. This is a critical risk factor that requires
immediate nursing intervention.
4. A client is receiving a continuous heparin infusion for a DVT. The nurse notes that the activated
partial thromboplastin time (aPTT) is 135 seconds. What is the priority action?
A. Continue the infusion and document the finding
B. Stop the infusion and notify the healthcare provider
, C. Increase the dose of heparin per protocol
D. Obtain a stat prothrombin time (PT/INR)
CORRECT ANSWER : B
Rationale: A PTT of 135 seconds is excessively high and puts the client at imminent risk of life-
threatening hemorrhage. The nurse must stop the medication and notify the provider to prevent
bleeding complications.
5. A client post-thyroidectomy exhibits laryngeal stridor and respiratory distress. What is the
nurse's priority intervention?
A. Administer oxygen via nasal cannula
B. Prepare for emergency intubation and alert the surgical team
C. Obtain an X-ray to check for tracheal deviation
D. Administer a nebulized bronchodilator
CORRECT ANSWER : B
Rationale: Laryngeal stridor indicates severe upper airway obstruction secondary to edema or
injury, which is a medical emergency. Intubation is required immediately to ensure airway
patency.
6. A nurse is caring for a client with type 1 diabetes who is experiencing an episode of symptomatic
hypoglycemia (blood glucose 45 mg/dL). The client is alert and able to swallow. What is the
priority?
A. Administer 10 units of regular insulin
B. Provide 15 grams of a fast-acting oral carbohydrate
C. Obtain a venous blood glucose sample
D. Place the client in the Trendelenburg position
CORRECT ANSWER : B
Rationale: The 15-gram rule for hypoglycemia is the immediate intervention for a conscious
client. Insulin would further lower blood glucose, and other diagnostic tests should not delay
acute glucose replacement.
, 7. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal
cannula. The nurse notes the client is becoming increasingly lethargic. What is the most
appropriate action?
A. Increase the oxygen flow rate
B. Assess the client's respiratory rate and obtain an ABG
C. Remove the oxygen to prevent CO2 retention
D. Notify the provider for sedation
CORRECT ANSWER : B
Rationale: Increased lethargy in a COPD client may indicate CO2 narcosis or respiratory
failure. An assessment of breathing patterns and blood gas analysis are necessary to determine if
the oxygen level is contributing to hypercapnia.
8. A nurse is caring for a client with a nasogastric tube. Prior to administering a scheduled feeding,
the nurse should prioritize which safety action?
A. Measuring the length of the tube from the nostril
B. Verifying the pH of the aspirated gastric contents
C. Flushing the tube with 50 mL of water
D. Positioning the client in the prone position
CORRECT ANSWER : B
Rationale: Verifying placement via pH testing is a reliable method to ensure the tube is in the
stomach and not the lungs, thereby preventing aspiration. While positioning (head elevation) is
important, placement confirmation is the primary safety check.
9. A nurse is preparing a sterile field. Which action constitutes a break in sterile technique?
A. Placing the sterile package on a dry, clean surface
B. Reaching across the sterile field with a non-sterile object
C. Keeping sterile items within the visual field
D. Holding sterile equipment above the waist
CORRECT ANSWER : B
ASSESSMENT QUESTIONS AND CORRECT ANSWERS
(VERIFIED ANSWERS) PLUS RATIONALES 2026 Q&A
|LATEST EXAM UPDATE 2026/2027 EXAM with
Questions and Answers/Plus a Rationale Updated
2026 A+/Instant Download PDF
EXAM COVERAGE
1. Potential for Alterations in Body Systems
2. Therapeutic Procedures
3. Laboratory Values
4. System Specific Assessments
5. Diagnostic Tests
6. Changes in Vital Signs
7. Potential for Complications of Diagnostic Tests/Treatments/Procedures
1. A nurse is caring for a client who is 4 hours post-operative following a total knee arthroplasty.
The client reports sudden sharp chest pain and exhibits tachycardia (120 bpm) and tachypnea
(28/min). Which action is the priority?
A. Administer a PRN dose of hydromorphone for pain
B. Elevate the head of the bed and administer oxygen
C. Check the surgical site for signs of hematoma
D. Increase the rate of IV fluids to support the blood pressure
, CORRECT ANSWER : B
Rationale: The client's symptoms (sudden chest pain, tachycardia, tachypnea) indicate a
potential pulmonary embolism. Elevating the head of the bed and initiating oxygen addresses the
priority of airway and oxygenation before any other intervention.
2. A client receiving a packed red blood cell transfusion develops flank pain, fever, and chills.
What is the nurse's immediate action?
A. Slow the transfusion rate and monitor vital signs
B. Stop the transfusion immediately and maintain the line with normal saline
C. Administer diphenhydramine as a prophylactic measure
D. Notify the blood bank to re-verify the cross-match
CORRECT ANSWER : B
Rationale: Flank pain and fever during a transfusion are hallmarks of an acute hemolytic
reaction. The transfusion must be stopped immediately to minimize the volume of incompatible
blood administered, and the IV line should be kept patent with saline.
3. A nurse is reviewing the lab results of a client with heart failure. Which result is most concerning
in the context of digoxin therapy?
A. Serum sodium 138 mEq/L
B. Serum potassium 3.1 mEq/L
C. Blood urea nitrogen 18 mg/dL
D. Serum calcium 9.2 mg/dL
CORRECT ANSWER : B
Rationale: Hypokalemia significantly increases the sensitivity of the myocardium to digoxin,
predisposing the client to lethal arrhythmias. This is a critical risk factor that requires
immediate nursing intervention.
4. A client is receiving a continuous heparin infusion for a DVT. The nurse notes that the activated
partial thromboplastin time (aPTT) is 135 seconds. What is the priority action?
A. Continue the infusion and document the finding
B. Stop the infusion and notify the healthcare provider
, C. Increase the dose of heparin per protocol
D. Obtain a stat prothrombin time (PT/INR)
CORRECT ANSWER : B
Rationale: A PTT of 135 seconds is excessively high and puts the client at imminent risk of life-
threatening hemorrhage. The nurse must stop the medication and notify the provider to prevent
bleeding complications.
5. A client post-thyroidectomy exhibits laryngeal stridor and respiratory distress. What is the
nurse's priority intervention?
A. Administer oxygen via nasal cannula
B. Prepare for emergency intubation and alert the surgical team
C. Obtain an X-ray to check for tracheal deviation
D. Administer a nebulized bronchodilator
CORRECT ANSWER : B
Rationale: Laryngeal stridor indicates severe upper airway obstruction secondary to edema or
injury, which is a medical emergency. Intubation is required immediately to ensure airway
patency.
6. A nurse is caring for a client with type 1 diabetes who is experiencing an episode of symptomatic
hypoglycemia (blood glucose 45 mg/dL). The client is alert and able to swallow. What is the
priority?
A. Administer 10 units of regular insulin
B. Provide 15 grams of a fast-acting oral carbohydrate
C. Obtain a venous blood glucose sample
D. Place the client in the Trendelenburg position
CORRECT ANSWER : B
Rationale: The 15-gram rule for hypoglycemia is the immediate intervention for a conscious
client. Insulin would further lower blood glucose, and other diagnostic tests should not delay
acute glucose replacement.
, 7. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal
cannula. The nurse notes the client is becoming increasingly lethargic. What is the most
appropriate action?
A. Increase the oxygen flow rate
B. Assess the client's respiratory rate and obtain an ABG
C. Remove the oxygen to prevent CO2 retention
D. Notify the provider for sedation
CORRECT ANSWER : B
Rationale: Increased lethargy in a COPD client may indicate CO2 narcosis or respiratory
failure. An assessment of breathing patterns and blood gas analysis are necessary to determine if
the oxygen level is contributing to hypercapnia.
8. A nurse is caring for a client with a nasogastric tube. Prior to administering a scheduled feeding,
the nurse should prioritize which safety action?
A. Measuring the length of the tube from the nostril
B. Verifying the pH of the aspirated gastric contents
C. Flushing the tube with 50 mL of water
D. Positioning the client in the prone position
CORRECT ANSWER : B
Rationale: Verifying placement via pH testing is a reliable method to ensure the tube is in the
stomach and not the lungs, thereby preventing aspiration. While positioning (head elevation) is
important, placement confirmation is the primary safety check.
9. A nurse is preparing a sterile field. Which action constitutes a break in sterile technique?
A. Placing the sterile package on a dry, clean surface
B. Reaching across the sterile field with a non-sterile object
C. Keeping sterile items within the visual field
D. Holding sterile equipment above the waist
CORRECT ANSWER : B
