NCLEX RN Reduction of Risk
Potential Exam 5 Questions And
Correct Answers (Verified Answers)
Plus Rationales 2026 Q&A | Instant
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1. A client with a history of deep vein thrombosis is scheduled for a total knee
arthroplasty. The surgeon orders enoxaparin 40 mg subcutaneously once
daily for postoperative thromboembolism prophylaxis. The nurse
administers the first dose 12 hours after surgery. What is the primary
rationale for this timing?
Answer: A. To reduce the risk of surgical site hematoma formation while
maintaining effective anticoagulation
Rationale: The timing of postoperative enoxaparin administration is
critical for balancing thromboprophylaxis with bleeding risk.
Administering the first dose too early, such as immediately
postoperatively, significantly increases the risk of surgical site bleeding
and hematoma formation, which can compromise wound healing and
increase infection risk. Waiting 12 to 24 hours after surgery allows for
initial hemostasis to occur while still providing effective prophylaxis before
the hypercoagulable state peaks, typically around 48 hours
postoperatively. The half life of enoxaparin is approximately 4 to 5 hours,
and peak levels occur 3 to 5 hours after injection, so delaying the first dose
does not substantially reduce its efficacy against venous
thromboembolism. Administering the dose at 12 hours is supported by
current orthopedic guidelines and has been shown to reduce major
bleeding events without increasing VTE rates compared to earlier
administration. Options B, C, and D are incorrect because they reflect
, either outdated practices or misinterpretations of pharmacokinetics, and
they do not address the primary safety concern of bleeding at the surgical
site.
2. A 72 year old male client is admitted for an elective abdominal aortic
aneurysm repair. During the preoperative assessment, the nurse notes a
serum creatinine level of 2.1 mg/dL and a blood urea nitrogen level of 42
mg/dL. Which intervention should the nurse prioritize in the immediate
preoperative period to reduce the risk of acute kidney injury?
Answer: C. Ensure adequate intravenous hydration with isotonic
crystalloids and monitor urine output
Rationale: The client's elevated creatinine and BUN indicate preexisting
chronic kidney disease or prerenal azotemia, placing him at high risk for
acute kidney injury during and after major vascular surgery. The primary
modifiable risk factor for contrast induced nephropathy and hemodynamic
instability is volume depletion. Therefore, the nurse's priority is to
advocate for and implement a protocol of aggressive hydration with
isotonic crystalloids, such as normal saline or lactated Ringer's, typically at
a rate of 1 to 2 mL/kg per hour starting several hours before surgery, to
expand intravascular volume and maintain renal perfusion. Monitoring
urine output hourly is essential to assess the adequacy of hydration and to
detect early signs of oliguria, which would indicate worsening renal
function. While holding metformin (option A) is important for diabetic
clients to prevent lactic acidosis, it does not directly address the
immediate risk of hypoperfusion. Restricting fluids (option B) would be
contraindicated because it exacerbates prerenal azotemia. Administering
sodium bicarbonate (option D) is no longer recommended as a routine
prophylactic measure for AKI, and its use without clear indications could
lead to metabolic alkalosis. Thus, hydration and urine output monitoring
are the cornerstone interventions.
3. A 55 year old female client with no significant medical history is scheduled
for a screening colonoscopy. The nurse provides instructions for bowel
preparation using a polyethylene glycol electrolyte solution. Which client
, statement indicates a need for further teaching regarding the risk of
electrolyte imbalance?
Answer: D. "I will drink the entire solution as quickly as possible over one
hour to finish it sooner."
Rationale: The client's statement about consuming the entire polyethylene
glycol solution within one hour is a clear indication of misunderstanding,
which poses a significant risk for electrolyte disturbances and fluid
overload. The recommended ingestion schedule for bowel preparation is
typically to drink 8 ounces of the solution every 10 to 15 minutes,
gradually consuming the total volume (often 4 liters) over a period of 3 to
4 hours. This slow, steady intake allows the bowel to tolerate the volume
and reduces the risk of rapid shifts in sodium, potassium, and fluid
balance, which can lead to hyponatremia, hypernatremia, or cardiac
arrhythmias. Rapid ingestion can overwhelm the gastrointestinal tract,
causing nausea, vomiting, and inadequate cleaning, as well as increasing
the risk of aspiration. Options A, B, and C reflect accurate understanding
of the preparation process: maintaining a clear liquid diet minimizes
residual fecal material, staying near the bathroom is practical, and taking
the solution chilled improves palatability without increasing risk.
Therefore, the nurse must correct the misconception about the ingestion
rate to prevent potential electrolyte complications.
4. During the recovery phase of a client who underwent a partial
hepatectomy, the nurse observes that the surgical drain output is
serosanguineous and increases from 50 mL to 250 mL over a two hour
period. The client's blood pressure drops from 124/78 to 98/62 mmHg, and
the heart rate rises from 88 to 116 beats per minute. Which immediate
action should the nurse take to reduce the risk of hypovolemic shock?
Answer: B. Administer a rapid bolus of intravenous isotonic crystalloid
solution and notify the surgeon
Rationale: The dramatic increase in drain output accompanied by
hypotension and tachycardia are classic signs of intraabdominal
hemorrhage and impending hypovolemic shock. The surgical drain output
, of 250 mL over two hours, especially when blood tinged, indicates
significant active bleeding from the liver bed, which is highly vascular. The
priority action is to restore circulating volume to maintain organ perfusion
and prevent cardiovascular collapse. Rapid administration of an isotonic
crystalloid bolus, such as 500 to 1000 mL of normal saline or lactated
Ringer's, is the immediate first line therapy to expand the intravascular
volume. Simultaneously, the surgeon must be notified promptly because
surgical re exploration may be necessary to control the bleeding source.
Changing the client's position (option A) may temporarily increase venous
return but does not address the volume deficit. Applying a pressure
dressing (option C) is ineffective for intraabdominal bleeding and may
obscure the assessment. Obtaining blood for type and crossmatch (option
D) is important for eventual transfusion, but it should not delay the
immediate fluid resuscitation that is essential to prevent irreversible
shock. Therefore, the bolus and surgeon notification are the correct,
prioritized actions.
5. A 68 year old client with atrial fibrillation is taking warfarin for stroke
prevention. The INR result is 4.8, and the client has no signs of active
bleeding. The next dose of warfarin is due in two hours. What is the nurse's
most appropriate action regarding the administration of the scheduled
warfarin dose?
Answer: A. Withhold the scheduled dose of warfarin and notify the
healthcare provider
Rationale: An INR of 4.8 significantly exceeds the therapeutic target range
of 2.0 to 3.0 for atrial fibrillation, indicating a high risk of hemorrhagic
complications. The standard of care for a supratherapeutic INR in an
asymptomatic client is to withhold the next dose of warfarin and inform
the prescriber to obtain further instructions, which may include
administration of oral vitamin K if the INR is above 5.0 but below 9.0, or a
lower dose adjustment. Continuing the scheduled dose (option B) would
exacerbate the coagulopathy and increase the risk of intracranial
hemorrhage or gastrointestinal bleeding. Administering a reduced dose
Potential Exam 5 Questions And
Correct Answers (Verified Answers)
Plus Rationales 2026 Q&A | Instant
Download Pdf
1. A client with a history of deep vein thrombosis is scheduled for a total knee
arthroplasty. The surgeon orders enoxaparin 40 mg subcutaneously once
daily for postoperative thromboembolism prophylaxis. The nurse
administers the first dose 12 hours after surgery. What is the primary
rationale for this timing?
Answer: A. To reduce the risk of surgical site hematoma formation while
maintaining effective anticoagulation
Rationale: The timing of postoperative enoxaparin administration is
critical for balancing thromboprophylaxis with bleeding risk.
Administering the first dose too early, such as immediately
postoperatively, significantly increases the risk of surgical site bleeding
and hematoma formation, which can compromise wound healing and
increase infection risk. Waiting 12 to 24 hours after surgery allows for
initial hemostasis to occur while still providing effective prophylaxis before
the hypercoagulable state peaks, typically around 48 hours
postoperatively. The half life of enoxaparin is approximately 4 to 5 hours,
and peak levels occur 3 to 5 hours after injection, so delaying the first dose
does not substantially reduce its efficacy against venous
thromboembolism. Administering the dose at 12 hours is supported by
current orthopedic guidelines and has been shown to reduce major
bleeding events without increasing VTE rates compared to earlier
administration. Options B, C, and D are incorrect because they reflect
, either outdated practices or misinterpretations of pharmacokinetics, and
they do not address the primary safety concern of bleeding at the surgical
site.
2. A 72 year old male client is admitted for an elective abdominal aortic
aneurysm repair. During the preoperative assessment, the nurse notes a
serum creatinine level of 2.1 mg/dL and a blood urea nitrogen level of 42
mg/dL. Which intervention should the nurse prioritize in the immediate
preoperative period to reduce the risk of acute kidney injury?
Answer: C. Ensure adequate intravenous hydration with isotonic
crystalloids and monitor urine output
Rationale: The client's elevated creatinine and BUN indicate preexisting
chronic kidney disease or prerenal azotemia, placing him at high risk for
acute kidney injury during and after major vascular surgery. The primary
modifiable risk factor for contrast induced nephropathy and hemodynamic
instability is volume depletion. Therefore, the nurse's priority is to
advocate for and implement a protocol of aggressive hydration with
isotonic crystalloids, such as normal saline or lactated Ringer's, typically at
a rate of 1 to 2 mL/kg per hour starting several hours before surgery, to
expand intravascular volume and maintain renal perfusion. Monitoring
urine output hourly is essential to assess the adequacy of hydration and to
detect early signs of oliguria, which would indicate worsening renal
function. While holding metformin (option A) is important for diabetic
clients to prevent lactic acidosis, it does not directly address the
immediate risk of hypoperfusion. Restricting fluids (option B) would be
contraindicated because it exacerbates prerenal azotemia. Administering
sodium bicarbonate (option D) is no longer recommended as a routine
prophylactic measure for AKI, and its use without clear indications could
lead to metabolic alkalosis. Thus, hydration and urine output monitoring
are the cornerstone interventions.
3. A 55 year old female client with no significant medical history is scheduled
for a screening colonoscopy. The nurse provides instructions for bowel
preparation using a polyethylene glycol electrolyte solution. Which client
, statement indicates a need for further teaching regarding the risk of
electrolyte imbalance?
Answer: D. "I will drink the entire solution as quickly as possible over one
hour to finish it sooner."
Rationale: The client's statement about consuming the entire polyethylene
glycol solution within one hour is a clear indication of misunderstanding,
which poses a significant risk for electrolyte disturbances and fluid
overload. The recommended ingestion schedule for bowel preparation is
typically to drink 8 ounces of the solution every 10 to 15 minutes,
gradually consuming the total volume (often 4 liters) over a period of 3 to
4 hours. This slow, steady intake allows the bowel to tolerate the volume
and reduces the risk of rapid shifts in sodium, potassium, and fluid
balance, which can lead to hyponatremia, hypernatremia, or cardiac
arrhythmias. Rapid ingestion can overwhelm the gastrointestinal tract,
causing nausea, vomiting, and inadequate cleaning, as well as increasing
the risk of aspiration. Options A, B, and C reflect accurate understanding
of the preparation process: maintaining a clear liquid diet minimizes
residual fecal material, staying near the bathroom is practical, and taking
the solution chilled improves palatability without increasing risk.
Therefore, the nurse must correct the misconception about the ingestion
rate to prevent potential electrolyte complications.
4. During the recovery phase of a client who underwent a partial
hepatectomy, the nurse observes that the surgical drain output is
serosanguineous and increases from 50 mL to 250 mL over a two hour
period. The client's blood pressure drops from 124/78 to 98/62 mmHg, and
the heart rate rises from 88 to 116 beats per minute. Which immediate
action should the nurse take to reduce the risk of hypovolemic shock?
Answer: B. Administer a rapid bolus of intravenous isotonic crystalloid
solution and notify the surgeon
Rationale: The dramatic increase in drain output accompanied by
hypotension and tachycardia are classic signs of intraabdominal
hemorrhage and impending hypovolemic shock. The surgical drain output
, of 250 mL over two hours, especially when blood tinged, indicates
significant active bleeding from the liver bed, which is highly vascular. The
priority action is to restore circulating volume to maintain organ perfusion
and prevent cardiovascular collapse. Rapid administration of an isotonic
crystalloid bolus, such as 500 to 1000 mL of normal saline or lactated
Ringer's, is the immediate first line therapy to expand the intravascular
volume. Simultaneously, the surgeon must be notified promptly because
surgical re exploration may be necessary to control the bleeding source.
Changing the client's position (option A) may temporarily increase venous
return but does not address the volume deficit. Applying a pressure
dressing (option C) is ineffective for intraabdominal bleeding and may
obscure the assessment. Obtaining blood for type and crossmatch (option
D) is important for eventual transfusion, but it should not delay the
immediate fluid resuscitation that is essential to prevent irreversible
shock. Therefore, the bolus and surgeon notification are the correct,
prioritized actions.
5. A 68 year old client with atrial fibrillation is taking warfarin for stroke
prevention. The INR result is 4.8, and the client has no signs of active
bleeding. The next dose of warfarin is due in two hours. What is the nurse's
most appropriate action regarding the administration of the scheduled
warfarin dose?
Answer: A. Withhold the scheduled dose of warfarin and notify the
healthcare provider
Rationale: An INR of 4.8 significantly exceeds the therapeutic target range
of 2.0 to 3.0 for atrial fibrillation, indicating a high risk of hemorrhagic
complications. The standard of care for a supratherapeutic INR in an
asymptomatic client is to withhold the next dose of warfarin and inform
the prescriber to obtain further instructions, which may include
administration of oral vitamin K if the INR is above 5.0 but below 9.0, or a
lower dose adjustment. Continuing the scheduled dose (option B) would
exacerbate the coagulopathy and increase the risk of intracranial
hemorrhage or gastrointestinal bleeding. Administering a reduced dose
