NCLEX RN Reduction of Risk Potential
Exam 3 Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A | Instant Download Pdf
1. A client is scheduled for a cardiac catheterization via the femoral artery.
Which pre-procedure assessment finding is most important for the nurse to
report to the healthcare provider?
A. Allergy to shellfish
B. Serum creatinine of 1.8 mg/dL
C. History of hypertension
D. Fasting blood glucose of 130 mg/dL
Correct Answer: B
Rationale: An elevated serum creatinine (1.8 mg/dL) indicates impaired renal
function, which increases the risk of contrast-induced nephropathy. While
shellfish allergy (A) was historically considered a contraindication due to iodine
content, current evidence shows that contrast reactions are not related to
shellfish allergy; however, any allergy should be reported, but renal function
takes priority. Hypertension (C) is common and managed. Fasting glucose of 130
mg/dL (D) indicates hyperglycemia but is not the highest risk for the procedure.
The nurse must prioritize kidney protection.
2. A nurse is monitoring a client 24 hours after a percutaneous liver biopsy.
Which finding requires immediate intervention?
A. Mild right upper quadrant discomfort
B. Pulse oximetry of 95% on room air
C. Sudden onset of shoulder pain and restlessness
D. Temperature of 99.2°F (37.3°C)
,Correct Answer: C
Rationale: Sudden shoulder pain (referred pain from diaphragmatic irritation)
and restlessness may indicate internal bleeding or pneumothorax, both life-
threatening complications after liver biopsy. Mild discomfort (A) is expected.
Oxygen saturation of 95% (B) is acceptable. Low-grade fever (D) can occur but is
not immediately life-threatening. The nurse should assess for signs of
hemorrhage and notify the provider promptly.
3. A client with a history of atrial fibrillation is receiving warfarin. The
international normalized ratio (INR) today is 4.8. The client is scheduled for
a dental extraction. What is the nurse's priority action?
A. Administer the scheduled warfarin dose
B. Hold the warfarin and notify the healthcare provider
C. Administer vitamin K subcutaneously
D. Proceed with the dental extraction as planned
Correct Answer: B
Rationale: An INR of 4.8 is supratherapeutic (target usually 2.0–3.5 for atrial
fibrillation) and poses a high risk of bleeding, especially before an invasive
procedure. The nurse should hold the warfarin and notify the provider for
further orders, which may include vitamin K or fresh frozen plasma.
Administering the dose (A) would increase bleeding risk. Vitamin K (C) requires a
provider order. Proceeding with extraction (D) is unsafe. The priority is
preventing hemorrhage.
4. A nurse is caring for a client who had a thoracentesis 30 minutes ago. The
client develops sudden sharp chest pain, dyspnea, and tracheal deviation to
the left. What should the nurse suspect?
A. Pulmonary embolism
B. Tension pneumothorax
C. Myocardial infarction
D. Pleural effusion recurrence
Correct Answer: B
Rationale: Sudden chest pain, dyspnea, and tracheal deviation away from the
,affected side (right-sided pneumothorax would cause deviation to the left)
indicate a tension pneumothorax, a life-threatening complication of
thoracentesis requiring immediate needle decompression. Pulmonary embolism
(A) may cause dyspnea and chest pain but not tracheal deviation. Myocardial
infarction (C) presents differently. Pleural effusion recurrence (D) would not
cause acute tracheal shift.
5. A client with chronic kidney disease is scheduled for a magnetic resonance
imaging (MRI) with gadolinium contrast. Which lab value is most
concerning?
A. Hemoglobin 10 g/dL
B. Serum potassium 5.1 mEq/L
C. Glomerular filtration rate (GFR) 22 mL/min
D. Serum calcium 8.8 mg/dL
Correct Answer: C
Rationale: Gadolinium-based contrast agents are contraindicated in severe renal
impairment (GFR <30 mL/min) due to the risk of nephrogenic systemic fibrosis. A
GFR of 22 mL/min indicates stage 4 CKD and poses a serious risk. Anemia (A),
mild hyperkalemia (B), and slightly low calcium (D) are common in CKD but do
not directly contraindicate gadolinium administration. The nurse must notify the
provider to consider alternative imaging.
6. A nurse is preparing a client for an electromyography (EMG). Which
instruction should the nurse include?
A. “You will be sedated for the procedure.”
B. “Avoid caffeine and smoking for 3 hours before the test.”
C. “The test requires a full bladder.”
D. “You will receive a contrast dye injection.”
Correct Answer: B
Rationale: Caffeine and nicotine can affect neuromuscular transmission and
should be avoided before EMG to ensure accurate results. Sedation (A) is not
typically used; the client remains awake. A full bladder (C) is not required. No
, contrast dye (D) is used; EMG involves needle electrodes. The nurse should
instruct the client that mild discomfort may occur during needle insertion.
7. A client returns from a transurethral resection of the prostate (TURP) with
continuous bladder irrigation. The nurse notes the drainage is bright red
with numerous clots. What is the priority action?
A. Increase the irrigation flow rate
B. Administer an antispasmodic
C. Notify the healthcare provider immediately
D. Irrigate the catheter manually with a syringe
Correct Answer: C
Rationale: Bright red drainage with clots may indicate arterial bleeding, a
surgical emergency. The nurse should first notify the provider while continuing
to monitor vital signs. Increasing irrigation rate (A) might be done per protocol
but requires provider guidance. Manual irrigation (D) can dislodge clots but may
also cause bladder perforation if not ordered. An antispasmodic (B) treats
bladder spasms, not bleeding. The priority is to communicate the change in
condition.
8. A nurse is monitoring a client during a blood transfusion. After 15 minutes,
the client reports chills, flank pain, and appears flushed. What type of
transfusion reaction does the nurse suspect?
A. Febrile non-hemolytic reaction
B. Acute hemolytic reaction
C. Allergic reaction
D. Circulatory overload
Correct Answer: B
Rationale: Chills, flank pain, and flushing occurring early in the transfusion are
classic signs of an acute hemolytic reaction, often due to ABO incompatibility.
This is a medical emergency. The nurse should stop the transfusion immediately,
maintain IV access with normal saline, and monitor renal function. Febrile
reaction (A) presents with fever and chills without flank pain. Allergic reaction
Exam 3 Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A | Instant Download Pdf
1. A client is scheduled for a cardiac catheterization via the femoral artery.
Which pre-procedure assessment finding is most important for the nurse to
report to the healthcare provider?
A. Allergy to shellfish
B. Serum creatinine of 1.8 mg/dL
C. History of hypertension
D. Fasting blood glucose of 130 mg/dL
Correct Answer: B
Rationale: An elevated serum creatinine (1.8 mg/dL) indicates impaired renal
function, which increases the risk of contrast-induced nephropathy. While
shellfish allergy (A) was historically considered a contraindication due to iodine
content, current evidence shows that contrast reactions are not related to
shellfish allergy; however, any allergy should be reported, but renal function
takes priority. Hypertension (C) is common and managed. Fasting glucose of 130
mg/dL (D) indicates hyperglycemia but is not the highest risk for the procedure.
The nurse must prioritize kidney protection.
2. A nurse is monitoring a client 24 hours after a percutaneous liver biopsy.
Which finding requires immediate intervention?
A. Mild right upper quadrant discomfort
B. Pulse oximetry of 95% on room air
C. Sudden onset of shoulder pain and restlessness
D. Temperature of 99.2°F (37.3°C)
,Correct Answer: C
Rationale: Sudden shoulder pain (referred pain from diaphragmatic irritation)
and restlessness may indicate internal bleeding or pneumothorax, both life-
threatening complications after liver biopsy. Mild discomfort (A) is expected.
Oxygen saturation of 95% (B) is acceptable. Low-grade fever (D) can occur but is
not immediately life-threatening. The nurse should assess for signs of
hemorrhage and notify the provider promptly.
3. A client with a history of atrial fibrillation is receiving warfarin. The
international normalized ratio (INR) today is 4.8. The client is scheduled for
a dental extraction. What is the nurse's priority action?
A. Administer the scheduled warfarin dose
B. Hold the warfarin and notify the healthcare provider
C. Administer vitamin K subcutaneously
D. Proceed with the dental extraction as planned
Correct Answer: B
Rationale: An INR of 4.8 is supratherapeutic (target usually 2.0–3.5 for atrial
fibrillation) and poses a high risk of bleeding, especially before an invasive
procedure. The nurse should hold the warfarin and notify the provider for
further orders, which may include vitamin K or fresh frozen plasma.
Administering the dose (A) would increase bleeding risk. Vitamin K (C) requires a
provider order. Proceeding with extraction (D) is unsafe. The priority is
preventing hemorrhage.
4. A nurse is caring for a client who had a thoracentesis 30 minutes ago. The
client develops sudden sharp chest pain, dyspnea, and tracheal deviation to
the left. What should the nurse suspect?
A. Pulmonary embolism
B. Tension pneumothorax
C. Myocardial infarction
D. Pleural effusion recurrence
Correct Answer: B
Rationale: Sudden chest pain, dyspnea, and tracheal deviation away from the
,affected side (right-sided pneumothorax would cause deviation to the left)
indicate a tension pneumothorax, a life-threatening complication of
thoracentesis requiring immediate needle decompression. Pulmonary embolism
(A) may cause dyspnea and chest pain but not tracheal deviation. Myocardial
infarction (C) presents differently. Pleural effusion recurrence (D) would not
cause acute tracheal shift.
5. A client with chronic kidney disease is scheduled for a magnetic resonance
imaging (MRI) with gadolinium contrast. Which lab value is most
concerning?
A. Hemoglobin 10 g/dL
B. Serum potassium 5.1 mEq/L
C. Glomerular filtration rate (GFR) 22 mL/min
D. Serum calcium 8.8 mg/dL
Correct Answer: C
Rationale: Gadolinium-based contrast agents are contraindicated in severe renal
impairment (GFR <30 mL/min) due to the risk of nephrogenic systemic fibrosis. A
GFR of 22 mL/min indicates stage 4 CKD and poses a serious risk. Anemia (A),
mild hyperkalemia (B), and slightly low calcium (D) are common in CKD but do
not directly contraindicate gadolinium administration. The nurse must notify the
provider to consider alternative imaging.
6. A nurse is preparing a client for an electromyography (EMG). Which
instruction should the nurse include?
A. “You will be sedated for the procedure.”
B. “Avoid caffeine and smoking for 3 hours before the test.”
C. “The test requires a full bladder.”
D. “You will receive a contrast dye injection.”
Correct Answer: B
Rationale: Caffeine and nicotine can affect neuromuscular transmission and
should be avoided before EMG to ensure accurate results. Sedation (A) is not
typically used; the client remains awake. A full bladder (C) is not required. No
, contrast dye (D) is used; EMG involves needle electrodes. The nurse should
instruct the client that mild discomfort may occur during needle insertion.
7. A client returns from a transurethral resection of the prostate (TURP) with
continuous bladder irrigation. The nurse notes the drainage is bright red
with numerous clots. What is the priority action?
A. Increase the irrigation flow rate
B. Administer an antispasmodic
C. Notify the healthcare provider immediately
D. Irrigate the catheter manually with a syringe
Correct Answer: C
Rationale: Bright red drainage with clots may indicate arterial bleeding, a
surgical emergency. The nurse should first notify the provider while continuing
to monitor vital signs. Increasing irrigation rate (A) might be done per protocol
but requires provider guidance. Manual irrigation (D) can dislodge clots but may
also cause bladder perforation if not ordered. An antispasmodic (B) treats
bladder spasms, not bleeding. The priority is to communicate the change in
condition.
8. A nurse is monitoring a client during a blood transfusion. After 15 minutes,
the client reports chills, flank pain, and appears flushed. What type of
transfusion reaction does the nurse suspect?
A. Febrile non-hemolytic reaction
B. Acute hemolytic reaction
C. Allergic reaction
D. Circulatory overload
Correct Answer: B
Rationale: Chills, flank pain, and flushing occurring early in the transfusion are
classic signs of an acute hemolytic reaction, often due to ABO incompatibility.
This is a medical emergency. The nurse should stop the transfusion immediately,
maintain IV access with normal saline, and monitor renal function. Febrile
reaction (A) presents with fever and chills without flank pain. Allergic reaction
