NCLEX RN Reduction of Risk Potential
Practice Exam 1 Questions And Correct
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Rationales 2026 Q&A | Instant
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1. A nurse is caring for a client who is 24 hours postoperative following
abdominal surgery. Which assessment finding requires the nurse's immediate
intervention?
A. Heart rate 88 beats per minute
B. Temperature 99.2°F (37.3°C)
C. Respiratory rate 22 breaths per minute
D. Oxygen saturation 89% on room air
Answer: D. Oxygen saturation 89% on room air
Rationale: An oxygen saturation of 89% indicates hypoxemia and requires
immediate intervention to prevent further complications such as tissue hypoxia,
organ dysfunction, or respiratory failure. Normal oxygen saturation should be
95% to 100%. A heart rate of 88 beats per minute is within normal range (60-
100). A temperature of 99.2°F is slightly elevated but expected postoperatively
due to the inflammatory response. A respiratory rate of 22 breaths per minute is
within normal range (12-20) though slightly elevated, which may indicate
compensation but does not require immediate intervention compared to the
hypoxemia.
,2. A client who is receiving total parenteral nutrition (TPN) through a central
venous catheter develops fever, chills, and hypotension. What is the nurse's
priority action?
A. Administer acetaminophen as prescribed
B. Increase the TPN infusion rate
C. Stop the TPN infusion immediately
D. Obtain blood cultures from the peripheral vein
Answer: C. Stop the TPN infusion immediately
Rationale: The client is exhibiting signs of catheter-related sepsis, which is a life-
threatening complication of TPN administration. The priority action is to stop
the TPN infusion immediately to prevent further introduction of microorganisms
into the bloodstream. After stopping the infusion, the nurse should notify the
healthcare provider, obtain blood cultures from both the catheter and a
peripheral site, and administer prescribed antibiotics. Administering
acetaminophen addresses the fever but does not address the source of infection.
Increasing the infusion rate would worsen the condition. Obtaining blood
cultures is important but should occur after stopping the infusion.
3. 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 identifiers
B. Check the client's vital signs before the transfusion
C. Prime the blood tubing with normal saline
D. Ensure the blood product is at room temperature
Answer: A. Verify the client's identity using two identifiers
Rationale: The most critical action to prevent transfusion reactions is verifying
the client's identity using two unique identifiers (e.g., name and date of birth)
and matching them to the blood product label and the client's identification
band. This ensures that the correct blood product is administered to the correct
,client, preventing ABO incompatibility reactions, which can be fatal. Checking
vital signs, priming tubing with normal saline, and ensuring proper temperature
are important but secondary to correct identification.
4. A postoperative client has a nasogastric (NG) tube connected to low
intermittent suction. Which finding indicates that the NG tube is functioning
properly?
A. The client reports nausea
B. The drainage is bright red
C. The drainage is greenish-yellow
D. The abdomen is distended
Answer: C. The drainage is greenish-yellow
Rationale: Greenish-yellow drainage from an NG tube indicates the presence of
gastric contents, which is expected when the tube is functioning properly and
effectively decompressing the stomach. Nausea and abdominal distention
suggest that the NG tube is not effectively removing gastric contents. Bright red
drainage indicates active bleeding and requires immediate notification of the
healthcare provider.
5. A nurse is assessing a client who has a new diagnosis of diabetes mellitus.
Which laboratory value indicates that the client is at risk for developing diabetic
ketoacidosis (DKA)?
A. Serum glucose 180 mg/dL
B. Serum potassium 4.0 mEq/L
C. Serum bicarbonate 18 mEq/L
D. Serum sodium 140 mEq/L
Answer: C. Serum bicarbonate 18 mEq/L
, Rationale: A serum bicarbonate level of 18 mEq/L indicates metabolic acidosis,
which is a hallmark of diabetic ketoacidosis. Normal bicarbonate levels range
from 22 to 26 mEq/L. In DKA, the body produces excess ketone bodies, leading to
a decrease in bicarbonate as the buffer system attempts to compensate for the
acidosis. A serum glucose of 180 mg/dL is elevated but not critically high for DKA
(which typically presents with glucose >250 mg/dL). Potassium and sodium
levels are within normal limits.
6. A client is prescribed enoxaparin (Lovenox) for deep vein thrombosis
prophylaxis following hip replacement surgery. Which laboratory value should
the nurse monitor before administering this medication?
A. Platelet count
B. White blood cell count
C. Hemoglobin
D. Serum creatinine
Answer: A. Platelet count
Rationale: Enoxaparin is a low-molecular-weight heparin that can cause
heparin-induced thrombocytopenia (HIT), a serious complication characterized
by a decrease in platelet count. The nurse should monitor the platelet count
before administration and regularly during therapy. A baseline platelet count is
essential to detect any subsequent drop that may indicate HIT. While
hemoglobin, white blood cell count, and serum creatinine are important to
monitor, they are not the primary laboratory values of concern for enoxaparin
administration.
7. A nurse is caring for a client with a central venous catheter. Which
intervention is most effective in reducing the risk of catheter-related
bloodstream infection?
Practice Exam 1 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A | Instant
Download Pdf
1. A nurse is caring for a client who is 24 hours postoperative following
abdominal surgery. Which assessment finding requires the nurse's immediate
intervention?
A. Heart rate 88 beats per minute
B. Temperature 99.2°F (37.3°C)
C. Respiratory rate 22 breaths per minute
D. Oxygen saturation 89% on room air
Answer: D. Oxygen saturation 89% on room air
Rationale: An oxygen saturation of 89% indicates hypoxemia and requires
immediate intervention to prevent further complications such as tissue hypoxia,
organ dysfunction, or respiratory failure. Normal oxygen saturation should be
95% to 100%. A heart rate of 88 beats per minute is within normal range (60-
100). A temperature of 99.2°F is slightly elevated but expected postoperatively
due to the inflammatory response. A respiratory rate of 22 breaths per minute is
within normal range (12-20) though slightly elevated, which may indicate
compensation but does not require immediate intervention compared to the
hypoxemia.
,2. A client who is receiving total parenteral nutrition (TPN) through a central
venous catheter develops fever, chills, and hypotension. What is the nurse's
priority action?
A. Administer acetaminophen as prescribed
B. Increase the TPN infusion rate
C. Stop the TPN infusion immediately
D. Obtain blood cultures from the peripheral vein
Answer: C. Stop the TPN infusion immediately
Rationale: The client is exhibiting signs of catheter-related sepsis, which is a life-
threatening complication of TPN administration. The priority action is to stop
the TPN infusion immediately to prevent further introduction of microorganisms
into the bloodstream. After stopping the infusion, the nurse should notify the
healthcare provider, obtain blood cultures from both the catheter and a
peripheral site, and administer prescribed antibiotics. Administering
acetaminophen addresses the fever but does not address the source of infection.
Increasing the infusion rate would worsen the condition. Obtaining blood
cultures is important but should occur after stopping the infusion.
3. 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 identifiers
B. Check the client's vital signs before the transfusion
C. Prime the blood tubing with normal saline
D. Ensure the blood product is at room temperature
Answer: A. Verify the client's identity using two identifiers
Rationale: The most critical action to prevent transfusion reactions is verifying
the client's identity using two unique identifiers (e.g., name and date of birth)
and matching them to the blood product label and the client's identification
band. This ensures that the correct blood product is administered to the correct
,client, preventing ABO incompatibility reactions, which can be fatal. Checking
vital signs, priming tubing with normal saline, and ensuring proper temperature
are important but secondary to correct identification.
4. A postoperative client has a nasogastric (NG) tube connected to low
intermittent suction. Which finding indicates that the NG tube is functioning
properly?
A. The client reports nausea
B. The drainage is bright red
C. The drainage is greenish-yellow
D. The abdomen is distended
Answer: C. The drainage is greenish-yellow
Rationale: Greenish-yellow drainage from an NG tube indicates the presence of
gastric contents, which is expected when the tube is functioning properly and
effectively decompressing the stomach. Nausea and abdominal distention
suggest that the NG tube is not effectively removing gastric contents. Bright red
drainage indicates active bleeding and requires immediate notification of the
healthcare provider.
5. A nurse is assessing a client who has a new diagnosis of diabetes mellitus.
Which laboratory value indicates that the client is at risk for developing diabetic
ketoacidosis (DKA)?
A. Serum glucose 180 mg/dL
B. Serum potassium 4.0 mEq/L
C. Serum bicarbonate 18 mEq/L
D. Serum sodium 140 mEq/L
Answer: C. Serum bicarbonate 18 mEq/L
, Rationale: A serum bicarbonate level of 18 mEq/L indicates metabolic acidosis,
which is a hallmark of diabetic ketoacidosis. Normal bicarbonate levels range
from 22 to 26 mEq/L. In DKA, the body produces excess ketone bodies, leading to
a decrease in bicarbonate as the buffer system attempts to compensate for the
acidosis. A serum glucose of 180 mg/dL is elevated but not critically high for DKA
(which typically presents with glucose >250 mg/dL). Potassium and sodium
levels are within normal limits.
6. A client is prescribed enoxaparin (Lovenox) for deep vein thrombosis
prophylaxis following hip replacement surgery. Which laboratory value should
the nurse monitor before administering this medication?
A. Platelet count
B. White blood cell count
C. Hemoglobin
D. Serum creatinine
Answer: A. Platelet count
Rationale: Enoxaparin is a low-molecular-weight heparin that can cause
heparin-induced thrombocytopenia (HIT), a serious complication characterized
by a decrease in platelet count. The nurse should monitor the platelet count
before administration and regularly during therapy. A baseline platelet count is
essential to detect any subsequent drop that may indicate HIT. While
hemoglobin, white blood cell count, and serum creatinine are important to
monitor, they are not the primary laboratory values of concern for enoxaparin
administration.
7. A nurse is caring for a client with a central venous catheter. Which
intervention is most effective in reducing the risk of catheter-related
bloodstream infection?
