NCLEX RN Reduction of Risk Potential
Practice Exam 1 100 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. Which
finding requires the nurse to stop the transfusion immediately?
A. Temperature increase of 0.2°C
B. Mild thirst
C. Chills, fever, and low back pain
D. Urinary frequency
Answer: Chills, fever, and low back pain
Rationale: Chills, fever, and low back pain can indicate an acute hemolytic
transfusion reaction. The nurse should stop the transfusion immediately,
maintain IV access with normal saline using new tubing, and notify the
provider and blood bank.
2. A client is receiving potassium chloride intravenously. Which nursing
action is appropriate?
A. Administer it by IV push
B. Mix it with blood products
C. Use an infusion pump and monitor the IV site
D. Administer it undiluted
Answer: Use an infusion pump and monitor the IV site
Rationale: IV potassium must be diluted and administered using a controlled
infusion device. IV push potassium can cause fatal cardiac dysrhythmias.
, 3. A nurse is monitoring a client after a thyroidectomy. Which finding
requires immediate intervention?
A. Hoarse voice
B. Mild incisional discomfort
C. Stridor and difficulty breathing
D. Sore throat
Answer: Stridor and difficulty breathing
Rationale: Stridor may indicate airway obstruction caused by edema,
hematoma, or injury to the laryngeal structures. Airway compromise is an
emergency.
4. A client is receiving heparin therapy. Which laboratory value is most
important for monitoring the therapeutic effect of unfractionated
heparin?
A. INR
B. Hemoglobin A1c
C. aPTT
D. Serum sodium
Answer: aPTT
Rationale: The activated partial thromboplastin time (aPTT) is commonly
used to monitor unfractionated heparin therapy and guide dose adjustments.
5. A nurse is caring for a client with a chest tube. Which finding indicates
that the system may be functioning normally?
A. Continuous bubbling in the water-seal chamber
B. Tidaling in the water-seal chamber
C. Chest tube disconnected from the drainage system
D. Absence of drainage immediately after insertion
Answer: Tidaling in the water-seal chamber
Rationale: Tidaling, or fluctuation of water with respiration, commonly
indicates that the chest tube system is patent and responding to changes in
intrathoracic pressure. Continuous bubbling may indicate an air leak.
, 6. A client is scheduled for a lumbar puncture. Which position should the
nurse anticipate?
A. Prone with legs extended
B. Supine with the head elevated
C. Side-lying with the back flexed
D. High-Fowler's position
Answer: Side-lying with the back flexed
Rationale: Side-lying with the spine flexed helps widen the spaces between
the vertebrae and facilitates insertion of the spinal needle.
7. A client receiving chemotherapy has a platelet count of 18,000/mm³.
Which intervention is most appropriate?
A. Encourage vigorous tooth brushing
B. Administer aspirin for headache
C. Institute bleeding precautions
D. Encourage contact sports
Answer: Institute bleeding precautions
Rationale: Severe thrombocytopenia increases the risk for spontaneous
bleeding. Bleeding precautions include avoiding invasive procedures, using a
soft toothbrush, and preventing injury.
8. A nurse is assessing a client with a central venous catheter. Which finding
should be reported immediately?
A. Dressing dated today
B. Mild tenderness immediately after insertion
C. Sudden dyspnea and chest pain
D. Catheter flushed according to protocol
Answer: Sudden dyspnea and chest pain
Rationale: Sudden dyspnea and chest pain after central line placement may
indicate pneumothorax or another serious complication requiring immediate
evaluation.
, 9. A client is receiving digoxin. Which assessment finding requires the nurse
to hold the medication and notify the provider?
A. Blood pressure of 128/76 mm Hg
B. Respiratory rate of 18/min
C. Apical pulse of 52/min
D. Temperature of 37°C
Answer: Apical pulse of 52/min
Rationale: Digoxin can cause bradycardia. The medication is generally
withheld when the adult apical pulse is below the prescribed safe threshold,
commonly 60/min.
10.A client with diabetes is scheduled for surgery. Which finding should the
nurse report before the procedure?
A. Blood glucose of 108 mg/dL
B. Blood pressure of 124/78 mm Hg
C. Blood glucose of 58 mg/dL
D. Heart rate of 82/min
Answer: Blood glucose of 58 mg/dL
Rationale: A glucose level of 58 mg/dL indicates hypoglycemia and requires
prompt treatment before surgery to reduce the risk of complications.
11.A nurse is preparing a client for a colonoscopy. Which finding should be
reported before the procedure?
A. Clear liquid diet the previous day
B. Mild anxiety
C. Incomplete bowel preparation
D. Request for privacy
Answer: Incomplete bowel preparation
Rationale: Adequate bowel cleansing is necessary for visualization of the
colon and safe completion of the procedure.
12.A client receiving a blood transfusion develops wheezing and respiratory
distress. What is the nurse's priority action?
Practice Exam 1 100 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. Which
finding requires the nurse to stop the transfusion immediately?
A. Temperature increase of 0.2°C
B. Mild thirst
C. Chills, fever, and low back pain
D. Urinary frequency
Answer: Chills, fever, and low back pain
Rationale: Chills, fever, and low back pain can indicate an acute hemolytic
transfusion reaction. The nurse should stop the transfusion immediately,
maintain IV access with normal saline using new tubing, and notify the
provider and blood bank.
2. A client is receiving potassium chloride intravenously. Which nursing
action is appropriate?
A. Administer it by IV push
B. Mix it with blood products
C. Use an infusion pump and monitor the IV site
D. Administer it undiluted
Answer: Use an infusion pump and monitor the IV site
Rationale: IV potassium must be diluted and administered using a controlled
infusion device. IV push potassium can cause fatal cardiac dysrhythmias.
, 3. A nurse is monitoring a client after a thyroidectomy. Which finding
requires immediate intervention?
A. Hoarse voice
B. Mild incisional discomfort
C. Stridor and difficulty breathing
D. Sore throat
Answer: Stridor and difficulty breathing
Rationale: Stridor may indicate airway obstruction caused by edema,
hematoma, or injury to the laryngeal structures. Airway compromise is an
emergency.
4. A client is receiving heparin therapy. Which laboratory value is most
important for monitoring the therapeutic effect of unfractionated
heparin?
A. INR
B. Hemoglobin A1c
C. aPTT
D. Serum sodium
Answer: aPTT
Rationale: The activated partial thromboplastin time (aPTT) is commonly
used to monitor unfractionated heparin therapy and guide dose adjustments.
5. A nurse is caring for a client with a chest tube. Which finding indicates
that the system may be functioning normally?
A. Continuous bubbling in the water-seal chamber
B. Tidaling in the water-seal chamber
C. Chest tube disconnected from the drainage system
D. Absence of drainage immediately after insertion
Answer: Tidaling in the water-seal chamber
Rationale: Tidaling, or fluctuation of water with respiration, commonly
indicates that the chest tube system is patent and responding to changes in
intrathoracic pressure. Continuous bubbling may indicate an air leak.
, 6. A client is scheduled for a lumbar puncture. Which position should the
nurse anticipate?
A. Prone with legs extended
B. Supine with the head elevated
C. Side-lying with the back flexed
D. High-Fowler's position
Answer: Side-lying with the back flexed
Rationale: Side-lying with the spine flexed helps widen the spaces between
the vertebrae and facilitates insertion of the spinal needle.
7. A client receiving chemotherapy has a platelet count of 18,000/mm³.
Which intervention is most appropriate?
A. Encourage vigorous tooth brushing
B. Administer aspirin for headache
C. Institute bleeding precautions
D. Encourage contact sports
Answer: Institute bleeding precautions
Rationale: Severe thrombocytopenia increases the risk for spontaneous
bleeding. Bleeding precautions include avoiding invasive procedures, using a
soft toothbrush, and preventing injury.
8. A nurse is assessing a client with a central venous catheter. Which finding
should be reported immediately?
A. Dressing dated today
B. Mild tenderness immediately after insertion
C. Sudden dyspnea and chest pain
D. Catheter flushed according to protocol
Answer: Sudden dyspnea and chest pain
Rationale: Sudden dyspnea and chest pain after central line placement may
indicate pneumothorax or another serious complication requiring immediate
evaluation.
, 9. A client is receiving digoxin. Which assessment finding requires the nurse
to hold the medication and notify the provider?
A. Blood pressure of 128/76 mm Hg
B. Respiratory rate of 18/min
C. Apical pulse of 52/min
D. Temperature of 37°C
Answer: Apical pulse of 52/min
Rationale: Digoxin can cause bradycardia. The medication is generally
withheld when the adult apical pulse is below the prescribed safe threshold,
commonly 60/min.
10.A client with diabetes is scheduled for surgery. Which finding should the
nurse report before the procedure?
A. Blood glucose of 108 mg/dL
B. Blood pressure of 124/78 mm Hg
C. Blood glucose of 58 mg/dL
D. Heart rate of 82/min
Answer: Blood glucose of 58 mg/dL
Rationale: A glucose level of 58 mg/dL indicates hypoglycemia and requires
prompt treatment before surgery to reduce the risk of complications.
11.A nurse is preparing a client for a colonoscopy. Which finding should be
reported before the procedure?
A. Clear liquid diet the previous day
B. Mild anxiety
C. Incomplete bowel preparation
D. Request for privacy
Answer: Incomplete bowel preparation
Rationale: Adequate bowel cleansing is necessary for visualization of the
colon and safe completion of the procedure.
12.A client receiving a blood transfusion develops wheezing and respiratory
distress. What is the nurse's priority action?
