NCLEX-RN Reduction of Risk Potential
Exam 3 Practice Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant Download
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1. A nurse is caring for a client receiving continuous cardiac monitoring after a
myocardial infarction. Which rhythm requires immediate intervention?
A. Normal sinus rhythm
B. Sinus bradycardia at 58/min
C. Ventricular fibrillation
D. First-degree atrioventricular block
Answer: C. Ventricular fibrillation
Rationale: Ventricular fibrillation produces no effective cardiac output and
requires immediate defibrillation and cardiopulmonary resuscitation.
2. A postoperative client suddenly reports shortness of breath and chest pain.
What is the nurse's priority action?
A. Encourage coughing
B. Apply oxygen and notify the rapid response team
,C. Offer oral fluids
D. Place the client in Trendelenburg position
Answer: B. Apply oxygen and notify the rapid response team
Rationale: These findings may indicate a pulmonary embolism. Immediate
oxygen administration and activation of emergency response are priorities.
3. Which assessment finding suggests increased intracranial pressure?
A. Bradycardia with hypertension
B. Tachycardia with hypotension
C. Fever with chills
D. Polyuria
Answer: A. Bradycardia with hypertension
Rationale: Cushing's triad includes hypertension, bradycardia, and irregular
respirations, indicating increased intracranial pressure.
4. A client receiving heparin develops bleeding gums. Which medication
should the nurse anticipate administering?
A. Vitamin K
B. Tranexamic acid
C. Protamine sulfate
D. Desmopressin
Answer: C. Protamine sulfate
Rationale: Protamine sulfate reverses the anticoagulant effects of heparin.
5. Which laboratory value requires immediate reporting?
,A. Sodium 138 mEq/L
B. Potassium 4.0 mEq/L
C. Potassium 6.2 mEq/L
D. Calcium 9.1 mg/dL
Answer: C. Potassium 6.2 mEq/L
Rationale: Severe hyperkalemia places the client at risk for life-threatening
cardiac dysrhythmias.
6. A nurse is monitoring a client after thyroidectomy. Which finding requires
immediate intervention?
A. Hoarseness
B. Mild sore throat
C. Stridor
D. Difficulty swallowing liquids
Answer: C. Stridor
Rationale: Stridor indicates airway obstruction and is a medical emergency
following thyroid surgery.
7. Which client is at greatest risk for aspiration?
A. Client with hypertension
B. Client with osteoarthritis
C. Client with impaired swallowing after a stroke
D. Client with cataracts
Answer: C. Client with impaired swallowing after a stroke
Rationale: Dysphagia significantly increases aspiration risk.
, 8. A nurse is preparing to administer packed red blood cells. Which action is
appropriate?
A. Prime tubing with dextrose solution
B. Warm blood in hot water
C. Use normal saline with blood administration tubing
D. Infuse over 8 hours
Answer: C. Use normal saline with blood administration tubing
Rationale: Normal saline is the only compatible solution for blood transfusions.
9. During a blood transfusion, the client develops chills and fever. What is the
nurse's first action?
A. Notify the provider
B. Document the findings
C. Stop the transfusion
D. Administer acetaminophen
Answer: C. Stop the transfusion
Rationale: The transfusion must be stopped immediately when a reaction is
suspected.
10.Which assessment finding is most concerning in a client receiving digoxin?
A. Pulse 84/min
B. Blood pressure 128/76 mm Hg
C. Heart rate 48/min
D. Respiratory rate 18/min
Answer: C. Heart rate 48/min
Rationale: Bradycardia is a sign of digoxin toxicity and requires withholding the
medication and notifying the provider.
Exam 3 Practice Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant Download
1. A nurse is caring for a client receiving continuous cardiac monitoring after a
myocardial infarction. Which rhythm requires immediate intervention?
A. Normal sinus rhythm
B. Sinus bradycardia at 58/min
C. Ventricular fibrillation
D. First-degree atrioventricular block
Answer: C. Ventricular fibrillation
Rationale: Ventricular fibrillation produces no effective cardiac output and
requires immediate defibrillation and cardiopulmonary resuscitation.
2. A postoperative client suddenly reports shortness of breath and chest pain.
What is the nurse's priority action?
A. Encourage coughing
B. Apply oxygen and notify the rapid response team
,C. Offer oral fluids
D. Place the client in Trendelenburg position
Answer: B. Apply oxygen and notify the rapid response team
Rationale: These findings may indicate a pulmonary embolism. Immediate
oxygen administration and activation of emergency response are priorities.
3. Which assessment finding suggests increased intracranial pressure?
A. Bradycardia with hypertension
B. Tachycardia with hypotension
C. Fever with chills
D. Polyuria
Answer: A. Bradycardia with hypertension
Rationale: Cushing's triad includes hypertension, bradycardia, and irregular
respirations, indicating increased intracranial pressure.
4. A client receiving heparin develops bleeding gums. Which medication
should the nurse anticipate administering?
A. Vitamin K
B. Tranexamic acid
C. Protamine sulfate
D. Desmopressin
Answer: C. Protamine sulfate
Rationale: Protamine sulfate reverses the anticoagulant effects of heparin.
5. Which laboratory value requires immediate reporting?
,A. Sodium 138 mEq/L
B. Potassium 4.0 mEq/L
C. Potassium 6.2 mEq/L
D. Calcium 9.1 mg/dL
Answer: C. Potassium 6.2 mEq/L
Rationale: Severe hyperkalemia places the client at risk for life-threatening
cardiac dysrhythmias.
6. A nurse is monitoring a client after thyroidectomy. Which finding requires
immediate intervention?
A. Hoarseness
B. Mild sore throat
C. Stridor
D. Difficulty swallowing liquids
Answer: C. Stridor
Rationale: Stridor indicates airway obstruction and is a medical emergency
following thyroid surgery.
7. Which client is at greatest risk for aspiration?
A. Client with hypertension
B. Client with osteoarthritis
C. Client with impaired swallowing after a stroke
D. Client with cataracts
Answer: C. Client with impaired swallowing after a stroke
Rationale: Dysphagia significantly increases aspiration risk.
, 8. A nurse is preparing to administer packed red blood cells. Which action is
appropriate?
A. Prime tubing with dextrose solution
B. Warm blood in hot water
C. Use normal saline with blood administration tubing
D. Infuse over 8 hours
Answer: C. Use normal saline with blood administration tubing
Rationale: Normal saline is the only compatible solution for blood transfusions.
9. During a blood transfusion, the client develops chills and fever. What is the
nurse's first action?
A. Notify the provider
B. Document the findings
C. Stop the transfusion
D. Administer acetaminophen
Answer: C. Stop the transfusion
Rationale: The transfusion must be stopped immediately when a reaction is
suspected.
10.Which assessment finding is most concerning in a client receiving digoxin?
A. Pulse 84/min
B. Blood pressure 128/76 mm Hg
C. Heart rate 48/min
D. Respiratory rate 18/min
Answer: C. Heart rate 48/min
Rationale: Bradycardia is a sign of digoxin toxicity and requires withholding the
medication and notifying the provider.
