NCLEX RN Reduction of Risk Potential
Exam 4 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant
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1. A nurse is assessing a client who is receiving a blood transfusion. Which
finding requires the nurse to stop the transfusion immediately?
A. Temperature of 37.2°C (99°F)
B. Mild fatigue
C. Chills and low back pain
D. Heart rate of 88/min
Answer: Chills and low back pain
Rationale: Chills and low back pain can indicate an acute hemolytic
transfusion reaction. The nurse should stop the transfusion, maintain IV
access with normal saline using new tubing, and notify the provider and
blood bank.
2. A client is scheduled for a lumbar puncture. Which position should the
nurse assist the client into?
A. Prone with legs extended
B. Side-lying with knees flexed toward the chest
C. Supine with the head elevated
D. High-Fowler position
Answer: Side-lying with knees flexed toward the chest
Rationale: Flexing the spine while the client is side-lying increases the space
between the vertebrae and facilitates insertion of the spinal needle.
, 3. A nurse is monitoring a client after a cardiac catheterization through the
femoral artery. Which finding requires immediate intervention?
A. Small bruise at the insertion site
B. Mild tenderness at the site
C. Absent pedal pulse in the affected extremity
D. Blood pressure of 128/76 mm Hg
Answer: Absent pedal pulse in the affected extremity
Rationale: An absent distal pulse may indicate arterial occlusion or impaired
circulation and requires immediate assessment and intervention.
4. A client is receiving potassium chloride intravenously. Which action is
appropriate?
A. Administer potassium by IV push
B. Infuse potassium rapidly if the serum level is low
C. Use an infusion pump
D. Mix potassium with blood products
Answer: Use an infusion pump
Rationale: IV potassium must be diluted and administered using a controlled
infusion device. IV push administration can cause fatal cardiac dysrhythmias.
5. A nurse is caring for a client after a thyroidectomy. Which finding is most
concerning?
A. Hoarse voice immediately after surgery
B. Mild incisional pain
C. Tingling around the mouth and fingers
D. Temperature of 37.1°C (98.8°F)
Answer: Tingling around the mouth and fingers
Rationale: Perioral and digital tingling can indicate hypocalcemia caused by
parathyroid injury or removal. Severe hypocalcemia can progress to tetany
and airway compromise.
6. A client is scheduled for a CT scan with iodinated contrast. Which history
is most important for the nurse to report?
,A. Seasonal allergies
B. Previous reaction to contrast media
C. History of constipation
D. Occasional headaches
Answer: Previous reaction to contrast media
Rationale: A previous reaction to iodinated contrast increases the risk of
another reaction. The healthcare team may need to modify the procedure or
administer premedication.
7. A nurse is monitoring a client receiving heparin. Which laboratory value
is used to evaluate the therapeutic effect of unfractionated heparin?
A. INR
B. aPTT
C. Platelet count only
D. Hemoglobin A1c
Answer: aPTT
Rationale: The activated partial thromboplastin time is commonly used to
monitor unfractionated heparin therapy.
8. A client receiving chemotherapy has a platelet count of 18,000/mm³.
Which intervention is most appropriate?
A. Encourage vigorous tooth brushing
B. Use an electric razor
C. Administer intramuscular injections
D. Encourage contact sports
Answer: Use an electric razor
Rationale: Severe thrombocytopenia increases bleeding risk. Electric razors
reduce the risk of cuts compared with traditional blades.
9. A nurse is caring for a client with neutropenia. Which intervention is
appropriate?
A. Place fresh flowers in the room
B. Encourage visitors with recent infections to visit
, C. Perform meticulous hand hygiene
D. Serve raw fruits without washing them
Answer: Perform meticulous hand hygiene
Rationale: Neutropenic clients are highly susceptible to infection. Hand
hygiene is one of the most important measures for preventing transmission of
microorganisms.
10.A client is receiving a medication that can cause nephrotoxicity. Which
laboratory value should the nurse monitor most closely?
A. Serum creatinine
B. Hemoglobin
C. Serum calcium
D. Platelet count
Answer: Serum creatinine
Rationale: Serum creatinine is an important indicator of renal function and
may increase when kidney injury occurs.
11.A client is undergoing a bone marrow aspiration. Which site is commonly
used for an adult?
A. Sternum only
B. Posterior iliac crest
C. Radius
D. Tibia
Answer: Posterior iliac crest
Rationale: The posterior iliac crest is a common and safe site for bone marrow
aspiration in adults.
12.A nurse is preparing a client for an MRI. Which item should the nurse
remove before the procedure?
A. Cotton gown
B. Plastic identification bracelet
C. Metal jewelry
D. Paper documentation
Exam 4 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant
Download Pdf
1. A nurse is assessing a client who is receiving a blood transfusion. Which
finding requires the nurse to stop the transfusion immediately?
A. Temperature of 37.2°C (99°F)
B. Mild fatigue
C. Chills and low back pain
D. Heart rate of 88/min
Answer: Chills and low back pain
Rationale: Chills and low back pain can indicate an acute hemolytic
transfusion reaction. The nurse should stop the transfusion, maintain IV
access with normal saline using new tubing, and notify the provider and
blood bank.
2. A client is scheduled for a lumbar puncture. Which position should the
nurse assist the client into?
A. Prone with legs extended
B. Side-lying with knees flexed toward the chest
C. Supine with the head elevated
D. High-Fowler position
Answer: Side-lying with knees flexed toward the chest
Rationale: Flexing the spine while the client is side-lying increases the space
between the vertebrae and facilitates insertion of the spinal needle.
, 3. A nurse is monitoring a client after a cardiac catheterization through the
femoral artery. Which finding requires immediate intervention?
A. Small bruise at the insertion site
B. Mild tenderness at the site
C. Absent pedal pulse in the affected extremity
D. Blood pressure of 128/76 mm Hg
Answer: Absent pedal pulse in the affected extremity
Rationale: An absent distal pulse may indicate arterial occlusion or impaired
circulation and requires immediate assessment and intervention.
4. A client is receiving potassium chloride intravenously. Which action is
appropriate?
A. Administer potassium by IV push
B. Infuse potassium rapidly if the serum level is low
C. Use an infusion pump
D. Mix potassium with blood products
Answer: Use an infusion pump
Rationale: IV potassium must be diluted and administered using a controlled
infusion device. IV push administration can cause fatal cardiac dysrhythmias.
5. A nurse is caring for a client after a thyroidectomy. Which finding is most
concerning?
A. Hoarse voice immediately after surgery
B. Mild incisional pain
C. Tingling around the mouth and fingers
D. Temperature of 37.1°C (98.8°F)
Answer: Tingling around the mouth and fingers
Rationale: Perioral and digital tingling can indicate hypocalcemia caused by
parathyroid injury or removal. Severe hypocalcemia can progress to tetany
and airway compromise.
6. A client is scheduled for a CT scan with iodinated contrast. Which history
is most important for the nurse to report?
,A. Seasonal allergies
B. Previous reaction to contrast media
C. History of constipation
D. Occasional headaches
Answer: Previous reaction to contrast media
Rationale: A previous reaction to iodinated contrast increases the risk of
another reaction. The healthcare team may need to modify the procedure or
administer premedication.
7. A nurse is monitoring a client receiving heparin. Which laboratory value
is used to evaluate the therapeutic effect of unfractionated heparin?
A. INR
B. aPTT
C. Platelet count only
D. Hemoglobin A1c
Answer: aPTT
Rationale: The activated partial thromboplastin time is commonly used to
monitor unfractionated heparin therapy.
8. A client receiving chemotherapy has a platelet count of 18,000/mm³.
Which intervention is most appropriate?
A. Encourage vigorous tooth brushing
B. Use an electric razor
C. Administer intramuscular injections
D. Encourage contact sports
Answer: Use an electric razor
Rationale: Severe thrombocytopenia increases bleeding risk. Electric razors
reduce the risk of cuts compared with traditional blades.
9. A nurse is caring for a client with neutropenia. Which intervention is
appropriate?
A. Place fresh flowers in the room
B. Encourage visitors with recent infections to visit
, C. Perform meticulous hand hygiene
D. Serve raw fruits without washing them
Answer: Perform meticulous hand hygiene
Rationale: Neutropenic clients are highly susceptible to infection. Hand
hygiene is one of the most important measures for preventing transmission of
microorganisms.
10.A client is receiving a medication that can cause nephrotoxicity. Which
laboratory value should the nurse monitor most closely?
A. Serum creatinine
B. Hemoglobin
C. Serum calcium
D. Platelet count
Answer: Serum creatinine
Rationale: Serum creatinine is an important indicator of renal function and
may increase when kidney injury occurs.
11.A client is undergoing a bone marrow aspiration. Which site is commonly
used for an adult?
A. Sternum only
B. Posterior iliac crest
C. Radius
D. Tibia
Answer: Posterior iliac crest
Rationale: The posterior iliac crest is a common and safe site for bone marrow
aspiration in adults.
12.A nurse is preparing a client for an MRI. Which item should the nurse
remove before the procedure?
A. Cotton gown
B. Plastic identification bracelet
C. Metal jewelry
D. Paper documentation
