NCLEX RN Reduction of Risk Potential
Exam 2 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant
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1.
A nurse is caring for a client who is receiving a blood transfusion. Fifteen
minutes after the transfusion begins, the client reports chills and low back pain.
What is the nurse’s priority action?
A. Slow the transfusion rate
B. Administer prescribed acetaminophen
C. Stop the transfusion immediately
D. Obtain another set of vital signs
Answer: C. Stop the transfusion immediately
Rationale: An acute hemolytic transfusion reaction can be life-threatening.
The nurse should stop the transfusion, maintain IV access with normal saline
using new tubing, notify the provider and blood bank, and monitor the client
closely.
2.
A client is receiving potassium chloride intravenously. Which assessment
finding requires the nurse’s immediate attention?
A. Potassium level of 3.6 mEq/L
B. Urine output of 45 mL/hr
,C. Burning at the IV site
D. Heart rate of 82/min
Answer: C. Burning at the IV site
Rationale: IV potassium can cause severe tissue injury if infiltration or
extravasation occurs. The nurse should stop the infusion and assess the IV site
immediately.
3.
A nurse is preparing a client for a lumbar puncture. Which finding should be
reported to the provider before the procedure?
A. Mild headache
B. Platelet count of 45,000/mm³
C. Temperature of 37.2°C (99°F)
D. History of seasonal allergies
Answer: B. Platelet count of 45,000/mm³
Rationale: Severe thrombocytopenia increases the risk of bleeding and spinal
hematoma during lumbar puncture. The procedure may need to be delayed
until the bleeding risk is addressed.
4.
A client receiving digoxin has an apical pulse of 52/min. Which action should
the nurse take?
A. Administer the medication as prescribed
B. Hold the medication and notify the provider
C. Give the medication with food
D. Recheck the pulse after ambulation
Answer: B. Hold the medication and notify the provider
Rationale: Digoxin can cause bradycardia. An adult apical pulse below
60/min is generally a reason to withhold digoxin and notify the provider.
,5.
A client is receiving heparin therapy. Which laboratory value is most important
for the nurse to monitor?
A. INR
B. aPTT
C. Hemoglobin A1c
D. Serum sodium
Answer: B. aPTT
Rationale: The activated partial thromboplastin time is commonly used to
monitor therapeutic unfractionated heparin therapy.
6.
A nurse is monitoring a client after a cardiac catheterization performed through
the femoral artery. Which finding requires immediate intervention?
A. Small ecchymosis at the insertion site
B. Pedal pulse 2+ bilaterally
C. Sudden severe back pain and hypotension
D. Mild tenderness at the insertion site
Answer: C. Sudden severe back pain and hypotension
Rationale: Severe back pain with hypotension after femoral catheterization
may indicate retroperitoneal bleeding, which requires immediate
intervention.
7.
A client receiving chemotherapy has an absolute neutrophil count of 400/mm³.
Which nursing intervention is appropriate?
A. Place fresh flowers in the room
B. Encourage raw fruits and vegetables
, C. Avoid exposure to people with infections
D. Encourage rectal temperature measurements
Answer: C. Avoid exposure to people with infections
Rationale: Severe neutropenia increases the risk of infection. The client
should avoid sick contacts and receive meticulous infection-prevention care.
8.
A client with diabetes is scheduled for surgery. Which finding should the nurse
report before the procedure?
A. Blood glucose of 168 mg/dL
B. Hemoglobin of 13 g/dL
C. Potassium of 4.2 mEq/L
D. Temperature of 36.8°C (98.2°F)
Answer: A. Blood glucose of 168 mg/dL
Rationale: Hyperglycemia can increase the risk of infection and delayed
wound healing. The nurse should report elevated glucose levels according to
the facility’s perioperative protocol.
9.
A client receiving IV fluids develops dyspnea, crackles, and an oxygen
saturation of 88%. What should the nurse do first?
A. Increase the IV infusion rate
B. Place the client in high-Fowler’s position
C. Encourage oral fluids
D. Place the client flat
Answer: B. Place the client in high-Fowler’s position
Rationale: These findings suggest fluid overload and pulmonary edema.
Positioning the client upright improves lung expansion and oxygenation while
additional interventions are initiated.
Exam 2 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant
Download Pdf
1.
A nurse is caring for a client who is receiving a blood transfusion. Fifteen
minutes after the transfusion begins, the client reports chills and low back pain.
What is the nurse’s priority action?
A. Slow the transfusion rate
B. Administer prescribed acetaminophen
C. Stop the transfusion immediately
D. Obtain another set of vital signs
Answer: C. Stop the transfusion immediately
Rationale: An acute hemolytic transfusion reaction can be life-threatening.
The nurse should stop the transfusion, maintain IV access with normal saline
using new tubing, notify the provider and blood bank, and monitor the client
closely.
2.
A client is receiving potassium chloride intravenously. Which assessment
finding requires the nurse’s immediate attention?
A. Potassium level of 3.6 mEq/L
B. Urine output of 45 mL/hr
,C. Burning at the IV site
D. Heart rate of 82/min
Answer: C. Burning at the IV site
Rationale: IV potassium can cause severe tissue injury if infiltration or
extravasation occurs. The nurse should stop the infusion and assess the IV site
immediately.
3.
A nurse is preparing a client for a lumbar puncture. Which finding should be
reported to the provider before the procedure?
A. Mild headache
B. Platelet count of 45,000/mm³
C. Temperature of 37.2°C (99°F)
D. History of seasonal allergies
Answer: B. Platelet count of 45,000/mm³
Rationale: Severe thrombocytopenia increases the risk of bleeding and spinal
hematoma during lumbar puncture. The procedure may need to be delayed
until the bleeding risk is addressed.
4.
A client receiving digoxin has an apical pulse of 52/min. Which action should
the nurse take?
A. Administer the medication as prescribed
B. Hold the medication and notify the provider
C. Give the medication with food
D. Recheck the pulse after ambulation
Answer: B. Hold the medication and notify the provider
Rationale: Digoxin can cause bradycardia. An adult apical pulse below
60/min is generally a reason to withhold digoxin and notify the provider.
,5.
A client is receiving heparin therapy. Which laboratory value is most important
for the nurse to monitor?
A. INR
B. aPTT
C. Hemoglobin A1c
D. Serum sodium
Answer: B. aPTT
Rationale: The activated partial thromboplastin time is commonly used to
monitor therapeutic unfractionated heparin therapy.
6.
A nurse is monitoring a client after a cardiac catheterization performed through
the femoral artery. Which finding requires immediate intervention?
A. Small ecchymosis at the insertion site
B. Pedal pulse 2+ bilaterally
C. Sudden severe back pain and hypotension
D. Mild tenderness at the insertion site
Answer: C. Sudden severe back pain and hypotension
Rationale: Severe back pain with hypotension after femoral catheterization
may indicate retroperitoneal bleeding, which requires immediate
intervention.
7.
A client receiving chemotherapy has an absolute neutrophil count of 400/mm³.
Which nursing intervention is appropriate?
A. Place fresh flowers in the room
B. Encourage raw fruits and vegetables
, C. Avoid exposure to people with infections
D. Encourage rectal temperature measurements
Answer: C. Avoid exposure to people with infections
Rationale: Severe neutropenia increases the risk of infection. The client
should avoid sick contacts and receive meticulous infection-prevention care.
8.
A client with diabetes is scheduled for surgery. Which finding should the nurse
report before the procedure?
A. Blood glucose of 168 mg/dL
B. Hemoglobin of 13 g/dL
C. Potassium of 4.2 mEq/L
D. Temperature of 36.8°C (98.2°F)
Answer: A. Blood glucose of 168 mg/dL
Rationale: Hyperglycemia can increase the risk of infection and delayed
wound healing. The nurse should report elevated glucose levels according to
the facility’s perioperative protocol.
9.
A client receiving IV fluids develops dyspnea, crackles, and an oxygen
saturation of 88%. What should the nurse do first?
A. Increase the IV infusion rate
B. Place the client in high-Fowler’s position
C. Encourage oral fluids
D. Place the client flat
Answer: B. Place the client in high-Fowler’s position
Rationale: These findings suggest fluid overload and pulmonary edema.
Positioning the client upright improves lung expansion and oxygenation while
additional interventions are initiated.
