NCLEX-RN Reduction of Risk Potential
Practice Exam 2 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A | Instant
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Question 1
A nurse is caring for a postoperative client who had abdominal surgery 8 hours
ago. Which assessment finding requires immediate intervention?
A. Serosanguinous drainage on the surgical dressing measuring 4 cm in diameter
B. Urine output of 40 mL over the past 2 hours
C. Oxygen saturation of 92% on room air
D. Pain rated 4 out of 10 on a 0-to-10 scale
Answer: B
Rationale: Urine output of 40 mL over 2 hours equals 20 mL/hour, which is below
the minimum acceptable output of 30 mL/hour. This finding suggests decreased
renal perfusion and may indicate hypovolemia, hemorrhage, or acute kidney
injury. The nurse should immediately notify the healthcare provider and assess
for additional signs of fluid volume deficit. Serosanguinous drainage on a
postoperative dressing is expected within the first 24 to 48 hours. An oxygen
saturation of 92% requires monitoring and intervention but is not immediately
life-threatening. Pain rated 4 out of 10 is moderate and should be addressed,
but it does not take priority over potential renal compromise.
,Question 2
Which action is most effective in preventing catheter-associated urinary tract
infections (CAUTI)?
A. Performing routine catheter irrigation with sterile normal saline
B. Administering prophylactic antibiotics daily
C. Maintaining a closed urinary drainage system
D. Emptying the drainage bag every 4 hours
Answer: C
Rationale: Maintaining a closed urinary drainage system is the single most
effective strategy for preventing CAUTI because it prevents bacteria from
entering the urinary tract through the catheter lumen. The closed system should
never be broken except for necessary procedures performed using sterile
technique. Routine catheter irrigation is not recommended and actually
increases the risk of infection by introducing bacteria. Prophylactic antibiotics
are not indicated for CAUTI prevention and contribute to antibiotic resistance.
Emptying the drainage bag every 4 hours is appropriate but does not prevent
infection as effectively as maintaining a closed system.
Question 3
A client is at risk for aspiration pneumonia. Which intervention should the nurse
implement to reduce this risk?
A. Keep the head of the bed flat during feedings
B. Elevate the head of the bed to 30 to 45 degrees during and after feedings
C. Position the client in the left lateral position during meals
D. Offer only thickened liquids to all clients at risk
Answer: B
Rationale: Elevating the head of the bed to 30 to 45 degrees during and after
feedings is the standard intervention to reduce aspiration risk. This position uses
,gravity to keep gastric contents in the stomach and prevents regurgitation and
aspiration into the lungs. Keeping the head of the bed flat significantly increases
aspiration risk. While the left lateral position may be beneficial for some clients,
the semi-Fowler's position is the preferred intervention. Thickened liquids may
be appropriate for clients with dysphagia but are not indicated for all clients at
risk for aspiration.
Question 4
The nurse reviews laboratory results for a client and notes a serum potassium
level of 6.2 mEq/L. Which action should the nurse take first?
A. Document the finding in the client's medical record
B. Notify the healthcare provider immediately
C. Prepare to administer potassium-wasting diuretics
D. Encourage the client to increase oral fluid intake
Answer: B
Rationale: A serum potassium level of 6.2 mEq/L is critically elevated (normal
range 3.5 to 5.0 mEq/L) and places the client at risk for life-threatening cardiac
dysrhythmias. The nurse must notify the healthcare provider immediately for
further orders, which may include administration of calcium gluconate, insulin
with glucose, or sodium polystyrene sulfonate. Documentation should occur
after the provider has been notified. Potassium-wasting diuretics may be
ordered but require a provider prescription. Increasing fluid intake will not
effectively lower potassium levels and could be dangerous in clients with renal
impairment or fluid overload.
Question 5
Which client is at greatest risk for developing contrast-induced nephropathy
following a diagnostic imaging procedure?
, A. A 25-year-old athlete with no medical history
B. A 55-year-old client with type 2 diabetes mellitus and chronic kidney disease
C. A 40-year-old client with asthma
D. A 30-year-old client with seasonal allergies
Answer: B
Rationale: Clients with pre-existing renal impairment, particularly those with
diabetes mellitus and chronic kidney disease, are at the highest risk for contrast-
induced nephropathy. The combination of diabetes and kidney disease
significantly increases the risk of acute kidney injury following administration of
iodinated contrast media. Healthy individuals, clients with asthma, and those
with seasonal allergies are not at significantly increased risk for this
complication. Clients at risk should receive adequate hydration and, in some
cases, N-acetylcysteine before the procedure.
Question 6
A nurse is preparing to administer a blood transfusion to a client. Which action is
most important to reduce the risk of a transfusion reaction?
A. Verify the client's identity using two unique identifiers
B. Administer an antihistamine before starting the transfusion
C. Set the infusion rate to run over 4 hours
D. Warm the blood product to room temperature before administration
Answer: A
Rationale: Verification of client identity using two unique identifiers (such as
name and date of birth) is the most critical action to prevent transfusion
reactions caused by administration of blood to the wrong client. This verification
must be performed at the client's bedside and must match the blood product
label and the client's identification band. While premedication with
antihistamines may be ordered for clients with a history of allergic reactions, it is
not the most important action for all clients. Blood products should be infused
Practice Exam 2 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A | Instant
Download Pdf
Question 1
A nurse is caring for a postoperative client who had abdominal surgery 8 hours
ago. Which assessment finding requires immediate intervention?
A. Serosanguinous drainage on the surgical dressing measuring 4 cm in diameter
B. Urine output of 40 mL over the past 2 hours
C. Oxygen saturation of 92% on room air
D. Pain rated 4 out of 10 on a 0-to-10 scale
Answer: B
Rationale: Urine output of 40 mL over 2 hours equals 20 mL/hour, which is below
the minimum acceptable output of 30 mL/hour. This finding suggests decreased
renal perfusion and may indicate hypovolemia, hemorrhage, or acute kidney
injury. The nurse should immediately notify the healthcare provider and assess
for additional signs of fluid volume deficit. Serosanguinous drainage on a
postoperative dressing is expected within the first 24 to 48 hours. An oxygen
saturation of 92% requires monitoring and intervention but is not immediately
life-threatening. Pain rated 4 out of 10 is moderate and should be addressed,
but it does not take priority over potential renal compromise.
,Question 2
Which action is most effective in preventing catheter-associated urinary tract
infections (CAUTI)?
A. Performing routine catheter irrigation with sterile normal saline
B. Administering prophylactic antibiotics daily
C. Maintaining a closed urinary drainage system
D. Emptying the drainage bag every 4 hours
Answer: C
Rationale: Maintaining a closed urinary drainage system is the single most
effective strategy for preventing CAUTI because it prevents bacteria from
entering the urinary tract through the catheter lumen. The closed system should
never be broken except for necessary procedures performed using sterile
technique. Routine catheter irrigation is not recommended and actually
increases the risk of infection by introducing bacteria. Prophylactic antibiotics
are not indicated for CAUTI prevention and contribute to antibiotic resistance.
Emptying the drainage bag every 4 hours is appropriate but does not prevent
infection as effectively as maintaining a closed system.
Question 3
A client is at risk for aspiration pneumonia. Which intervention should the nurse
implement to reduce this risk?
A. Keep the head of the bed flat during feedings
B. Elevate the head of the bed to 30 to 45 degrees during and after feedings
C. Position the client in the left lateral position during meals
D. Offer only thickened liquids to all clients at risk
Answer: B
Rationale: Elevating the head of the bed to 30 to 45 degrees during and after
feedings is the standard intervention to reduce aspiration risk. This position uses
,gravity to keep gastric contents in the stomach and prevents regurgitation and
aspiration into the lungs. Keeping the head of the bed flat significantly increases
aspiration risk. While the left lateral position may be beneficial for some clients,
the semi-Fowler's position is the preferred intervention. Thickened liquids may
be appropriate for clients with dysphagia but are not indicated for all clients at
risk for aspiration.
Question 4
The nurse reviews laboratory results for a client and notes a serum potassium
level of 6.2 mEq/L. Which action should the nurse take first?
A. Document the finding in the client's medical record
B. Notify the healthcare provider immediately
C. Prepare to administer potassium-wasting diuretics
D. Encourage the client to increase oral fluid intake
Answer: B
Rationale: A serum potassium level of 6.2 mEq/L is critically elevated (normal
range 3.5 to 5.0 mEq/L) and places the client at risk for life-threatening cardiac
dysrhythmias. The nurse must notify the healthcare provider immediately for
further orders, which may include administration of calcium gluconate, insulin
with glucose, or sodium polystyrene sulfonate. Documentation should occur
after the provider has been notified. Potassium-wasting diuretics may be
ordered but require a provider prescription. Increasing fluid intake will not
effectively lower potassium levels and could be dangerous in clients with renal
impairment or fluid overload.
Question 5
Which client is at greatest risk for developing contrast-induced nephropathy
following a diagnostic imaging procedure?
, A. A 25-year-old athlete with no medical history
B. A 55-year-old client with type 2 diabetes mellitus and chronic kidney disease
C. A 40-year-old client with asthma
D. A 30-year-old client with seasonal allergies
Answer: B
Rationale: Clients with pre-existing renal impairment, particularly those with
diabetes mellitus and chronic kidney disease, are at the highest risk for contrast-
induced nephropathy. The combination of diabetes and kidney disease
significantly increases the risk of acute kidney injury following administration of
iodinated contrast media. Healthy individuals, clients with asthma, and those
with seasonal allergies are not at significantly increased risk for this
complication. Clients at risk should receive adequate hydration and, in some
cases, N-acetylcysteine before the procedure.
Question 6
A nurse is preparing to administer a blood transfusion to a client. Which action is
most important to reduce the risk of a transfusion reaction?
A. Verify the client's identity using two unique identifiers
B. Administer an antihistamine before starting the transfusion
C. Set the infusion rate to run over 4 hours
D. Warm the blood product to room temperature before administration
Answer: A
Rationale: Verification of client identity using two unique identifiers (such as
name and date of birth) is the most critical action to prevent transfusion
reactions caused by administration of blood to the wrong client. This verification
must be performed at the client's bedside and must match the blood product
label and the client's identification band. While premedication with
antihistamines may be ordered for clients with a history of allergic reactions, it is
not the most important action for all clients. Blood products should be infused
