NCLEX RN Reduction of Risk Potential
Exam 4 Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A | Instant Download Pdf
1. A nurse is caring for a client who had a thoracentesis 30 minutes ago. Which
finding requires immediate intervention?
A. Small amount of serosanguineous drainage on the dressing.
B. Respiratory rate of 18 breaths per minute.
C. Tracheal deviation toward the unaffected side.
D. Client reports mild discomfort at the puncture site.
Answer: C
Rationale: Tracheal deviation toward the unaffected side indicates a tension
pneumothorax, a life-threatening complication of thoracentesis caused by air
accumulation in the pleural space that shifts mediastinal structures. This
requires immediate notification of the healthcare provider and preparation for
needle decompression or chest tube insertion. Serosanguineous drainage on the
dressing is an expected finding due to the invasive nature of the procedure. A
respiratory rate of 18 is within normal limits. Mild discomfort at the puncture
site is common and can be managed with analgesics; it is not an emergency.
2. A client is scheduled for a cardiac catheterization with femoral access.
Which pre-procedure nursing action is most important to reduce the risk of
complications?
A. Administer a sedative as prescribed.
B. Assess for allergy to iodine or shellfish.
C. Instruct the client to fast for 2 hours after the procedure.
D. Shave the groin area with a straight razor.
,Answer: B
Rationale: Assessing for allergy to iodine or shellfish is critical because the
contrast dye used during cardiac catheterization is iodine-based. An allergic
reaction can cause anaphylaxis, bronchospasm, or contrast-induced
nephropathy. The nurse must report any history of allergy so alternative
precautions or premedication can be ordered. Pre-procedure sedation is often
prescribed but is not the most important action for risk reduction. Fasting status
(usually NPO for 6-8 hours) is required before the procedure, not after. Hair
removal at the access site should be done with clippers, not a straight razor, to
prevent microabrasions and infection; shaving is no longer recommended.
3. A nurse is monitoring a client after a percutaneous liver biopsy. Which
position should the client be placed in immediately after the procedure?
A. High-Fowler's position.
B. Left side-lying with a pillow between the knees.
C. Right side-lying with a rolled towel under the puncture site.
D. Supine with the head of the bed flat.
Answer: C
Rationale: After a liver biopsy, the client should be positioned on the right side
with a small pillow or rolled towel under the puncture site for several hours. This
position applies pressure to the liver capsule against the abdominal wall,
promoting hemostasis and reducing the risk of bleeding. The liver is a highly
vascular organ, and hemorrhage is a significant complication. High-Fowler's
position would not provide direct pressure. Left side-lying would not compress
the liver, which is on the right. Supine with the head flat may be used for other
procedures but does not apply targeted pressure to the biopsy site.
4. A client with a history of chronic atrial fibrillation has an international
normalized ratio (INR) of 4.5. The nurse should anticipate which order?
A. Administer vitamin K.
B. Increase the warfarin dose.
C. Prepare for platelet transfusion.
D. Apply sequential compression devices.
,Answer: A
Rationale: A therapeutic INR for atrial fibrillation is typically 2.0-3.0. An INR of
4.5 places the client at high risk for bleeding. Vitamin K is the antidote for
warfarin and will promote synthesis of clotting factors to lower the INR. Fresh
frozen plasma may also be considered in active bleeding. Increasing the
warfarin dose would further elevate INR and increase bleeding risk. Platelet
transfusion is not indicated because warfarin affects clotting factors, not platelet
function. Sequential compression devices are for deep vein thrombosis
prophylaxis and have no effect on INR.
5. A nurse is caring for a client receiving total parenteral nutrition (TPN) via a
central line. Which action best reduces the risk of catheter-related
bloodstream infection?
A. Change the TPN bag and tubing every 72 hours.
B. Use sterile technique when changing the central line dressing.
C. Measure blood glucose every 6 hours.
D. Flush the line with heparin before each use.
Answer: B
Rationale: Central line-associated bloodstream infections (CLABSIs) are
prevented by strict aseptic technique during dressing changes, hub disinfection,
and line manipulation. The central line dressing should be changed using sterile
gloves, mask, and a sterile field whenever it becomes damp, loosened, or
according to facility policy. TPN tubing is changed every 24 hours, not 72 hours,
because the high glucose content promotes bacterial growth. Blood glucose
monitoring detects hyperglycemia, a metabolic complication, but does not
directly prevent infection. Heparin flushing maintains patency but does not
reduce infection risk.
6. A client is scheduled for a magnetic resonance imaging (MRI) scan with
contrast. Which question is most important for the nurse to ask before the
procedure?
A. "Have you ever had a reaction to latex?"
B. "Do you have any metal implants or pacemakers?"
, C. "When was your last menstrual period?"
D. "Are you allergic to eggs?"
Answer: B
Rationale: MRI uses a powerful magnetic field that can cause ferromagnetic
objects to move, heat, or malfunction, posing a serious safety risk. Any
implanted metal devices, such as pacemakers, aneurysm clips, cochlear
implants, or orthopedic hardware, must be identified because they may be
contraindicated or require special protocols. Gadolinium-based contrast agents
carry a risk of nephrogenic systemic fibrosis in clients with renal impairment, but
the immediate safety question concerns metal. Latex allergy is relevant for
procedures involving gloves or equipment. Menstrual history may be relevant
for pregnancy testing but is not the most critical safety issue. Egg allergy relates
to some vaccines and propofol, not MRI contrast.
7. A nurse is assessing a client who has a new permanent pacemaker. Which
finding indicates a potential complication of lead dislodgement or
perforation?
A. Heart rate of 72 beats per minute.
B. Report of persistent hiccups.
C. Blood pressure of 118/78 mm Hg.
D. Pacing spike before every QRS complex on the monitor.
Answer: B
Rationale: Persistent hiccups can indicate that the pacemaker lead has
perforated the myocardium and is stimulating the diaphragm or phrenic nerve,
which causes hiccuping. This is an uncommon but serious complication requiring
immediate evaluation. A heart rate at the set rate is expected. Stable blood
pressure is normal. A pacing spike before each QRS indicates capture, which is
the desired outcome of pacing.
8. A client develops sudden chest pain and shortness of breath 4 days after
open reduction and internal fixation of a hip fracture. The nurse notes
tachycardia and a low-grade fever. Which diagnostic test should the nurse
anticipate being ordered first?
Exam 4 Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A | Instant Download Pdf
1. A nurse is caring for a client who had a thoracentesis 30 minutes ago. Which
finding requires immediate intervention?
A. Small amount of serosanguineous drainage on the dressing.
B. Respiratory rate of 18 breaths per minute.
C. Tracheal deviation toward the unaffected side.
D. Client reports mild discomfort at the puncture site.
Answer: C
Rationale: Tracheal deviation toward the unaffected side indicates a tension
pneumothorax, a life-threatening complication of thoracentesis caused by air
accumulation in the pleural space that shifts mediastinal structures. This
requires immediate notification of the healthcare provider and preparation for
needle decompression or chest tube insertion. Serosanguineous drainage on the
dressing is an expected finding due to the invasive nature of the procedure. A
respiratory rate of 18 is within normal limits. Mild discomfort at the puncture
site is common and can be managed with analgesics; it is not an emergency.
2. A client is scheduled for a cardiac catheterization with femoral access.
Which pre-procedure nursing action is most important to reduce the risk of
complications?
A. Administer a sedative as prescribed.
B. Assess for allergy to iodine or shellfish.
C. Instruct the client to fast for 2 hours after the procedure.
D. Shave the groin area with a straight razor.
,Answer: B
Rationale: Assessing for allergy to iodine or shellfish is critical because the
contrast dye used during cardiac catheterization is iodine-based. An allergic
reaction can cause anaphylaxis, bronchospasm, or contrast-induced
nephropathy. The nurse must report any history of allergy so alternative
precautions or premedication can be ordered. Pre-procedure sedation is often
prescribed but is not the most important action for risk reduction. Fasting status
(usually NPO for 6-8 hours) is required before the procedure, not after. Hair
removal at the access site should be done with clippers, not a straight razor, to
prevent microabrasions and infection; shaving is no longer recommended.
3. A nurse is monitoring a client after a percutaneous liver biopsy. Which
position should the client be placed in immediately after the procedure?
A. High-Fowler's position.
B. Left side-lying with a pillow between the knees.
C. Right side-lying with a rolled towel under the puncture site.
D. Supine with the head of the bed flat.
Answer: C
Rationale: After a liver biopsy, the client should be positioned on the right side
with a small pillow or rolled towel under the puncture site for several hours. This
position applies pressure to the liver capsule against the abdominal wall,
promoting hemostasis and reducing the risk of bleeding. The liver is a highly
vascular organ, and hemorrhage is a significant complication. High-Fowler's
position would not provide direct pressure. Left side-lying would not compress
the liver, which is on the right. Supine with the head flat may be used for other
procedures but does not apply targeted pressure to the biopsy site.
4. A client with a history of chronic atrial fibrillation has an international
normalized ratio (INR) of 4.5. The nurse should anticipate which order?
A. Administer vitamin K.
B. Increase the warfarin dose.
C. Prepare for platelet transfusion.
D. Apply sequential compression devices.
,Answer: A
Rationale: A therapeutic INR for atrial fibrillation is typically 2.0-3.0. An INR of
4.5 places the client at high risk for bleeding. Vitamin K is the antidote for
warfarin and will promote synthesis of clotting factors to lower the INR. Fresh
frozen plasma may also be considered in active bleeding. Increasing the
warfarin dose would further elevate INR and increase bleeding risk. Platelet
transfusion is not indicated because warfarin affects clotting factors, not platelet
function. Sequential compression devices are for deep vein thrombosis
prophylaxis and have no effect on INR.
5. A nurse is caring for a client receiving total parenteral nutrition (TPN) via a
central line. Which action best reduces the risk of catheter-related
bloodstream infection?
A. Change the TPN bag and tubing every 72 hours.
B. Use sterile technique when changing the central line dressing.
C. Measure blood glucose every 6 hours.
D. Flush the line with heparin before each use.
Answer: B
Rationale: Central line-associated bloodstream infections (CLABSIs) are
prevented by strict aseptic technique during dressing changes, hub disinfection,
and line manipulation. The central line dressing should be changed using sterile
gloves, mask, and a sterile field whenever it becomes damp, loosened, or
according to facility policy. TPN tubing is changed every 24 hours, not 72 hours,
because the high glucose content promotes bacterial growth. Blood glucose
monitoring detects hyperglycemia, a metabolic complication, but does not
directly prevent infection. Heparin flushing maintains patency but does not
reduce infection risk.
6. A client is scheduled for a magnetic resonance imaging (MRI) scan with
contrast. Which question is most important for the nurse to ask before the
procedure?
A. "Have you ever had a reaction to latex?"
B. "Do you have any metal implants or pacemakers?"
, C. "When was your last menstrual period?"
D. "Are you allergic to eggs?"
Answer: B
Rationale: MRI uses a powerful magnetic field that can cause ferromagnetic
objects to move, heat, or malfunction, posing a serious safety risk. Any
implanted metal devices, such as pacemakers, aneurysm clips, cochlear
implants, or orthopedic hardware, must be identified because they may be
contraindicated or require special protocols. Gadolinium-based contrast agents
carry a risk of nephrogenic systemic fibrosis in clients with renal impairment, but
the immediate safety question concerns metal. Latex allergy is relevant for
procedures involving gloves or equipment. Menstrual history may be relevant
for pregnancy testing but is not the most critical safety issue. Egg allergy relates
to some vaccines and propofol, not MRI contrast.
7. A nurse is assessing a client who has a new permanent pacemaker. Which
finding indicates a potential complication of lead dislodgement or
perforation?
A. Heart rate of 72 beats per minute.
B. Report of persistent hiccups.
C. Blood pressure of 118/78 mm Hg.
D. Pacing spike before every QRS complex on the monitor.
Answer: B
Rationale: Persistent hiccups can indicate that the pacemaker lead has
perforated the myocardium and is stimulating the diaphragm or phrenic nerve,
which causes hiccuping. This is an uncommon but serious complication requiring
immediate evaluation. A heart rate at the set rate is expected. Stable blood
pressure is normal. A pacing spike before each QRS indicates capture, which is
the desired outcome of pacing.
8. A client develops sudden chest pain and shortness of breath 4 days after
open reduction and internal fixation of a hip fracture. The nurse notes
tachycardia and a low-grade fever. Which diagnostic test should the nurse
anticipate being ordered first?
