NCLEX RN Reduction of Risk Potential
Practice Exam 3 100 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 immediate intervention?
A. Temperature of 37.2°C (99°F)
B. Blood pressure of 128/76 mm Hg
C. Chills and low back pain
D. Pulse of 84/min
Answer: C. Chills and low back pain
Rationale: Chills 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. Which laboratory value should the nurse report immediately for a client
receiving heparin therapy?
A. Hemoglobin 13.2 g/dL
B. Platelet count 48,000/mm³
C. Sodium 138 mEq/L
D. Potassium 4.2 mEq/L
Answer: B. Platelet count 48,000/mm³
,Rationale: A markedly decreased platelet count may indicate heparin-induced
thrombocytopenia (HIT), which increases the risk of thrombosis and requires
prompt intervention.
3. A client is scheduled for a lumbar puncture. Which assessment finding
should the nurse report before the procedure?
A. Headache rated 3/10
B. Blood pressure of 124/78 mm Hg
C. Platelet count of 45,000/mm³
D. Temperature of 37°C (98.6°F)
Answer: C. Platelet count of 45,000/mm³
Rationale: Severe thrombocytopenia increases the risk of bleeding during
lumbar puncture and may require postponement of the procedure.
4. A nurse is monitoring a client after thyroidectomy. Which finding requires
immediate action?
A. Hoarse voice
B. Mild incisional pain
C. Stridor
D. Sore throat
Answer: C. Stridor
Rationale: Stridor indicates possible airway obstruction from edema,
bleeding, or laryngeal complications. Airway compromise is an emergency.
5. Which assessment finding is most concerning in a client receiving
magnesium sulfate?
A. Respiratory rate of 10/min
B. Urine output of 45 mL/hr
C. Patellar reflexes 2+
D. Blood pressure of 140/88 mm Hg
Answer: A. Respiratory rate of 10/min
,Rationale: Respiratory depression is a sign of magnesium toxicity. The
infusion should be stopped and calcium gluconate should be available as the
antidote.
6. A nurse is caring for a client with a central venous catheter. Which finding
suggests a catheter-related infection?
A. Clear dressing
B. Temperature of 39°C (102.2°F)
C. Blood pressure of 118/72 mm Hg
D. Catheter flushing easily
Answer: B. Temperature of 39°C (102.2°F)
Rationale: Fever in a client with a central venous catheter may indicate
bloodstream infection and requires prompt assessment and intervention.
7. A client with a chest tube suddenly develops severe dyspnea. The nurse
notes that the drainage system has become disconnected. What should the
nurse do first?
A. Clamp the chest tube
B. Place the end of the tube in sterile water
C. Remove the chest tube
D. Apply a dry dressing
Answer: B. Place the end of the tube in sterile water
Rationale: Placing the disconnected chest tube end in sterile water
temporarily restores a water seal and helps prevent air from entering the
pleural space.
8. Which finding indicates that a chest tube may be functioning improperly?
A. Tidaling in the water-seal chamber
B. Intermittent bubbling with coughing
C. Continuous vigorous bubbling in the water-seal chamber
D. Drainage of 50 mL during the first hour
Answer: C. Continuous vigorous bubbling in the water-seal chamber
, Rationale: Continuous bubbling may indicate an air leak in the system or from
the client. The nurse should assess the tubing and connections.
9. A client is receiving potassium chloride intravenously. Which nursing action
is appropriate?
A. Administer potassium by IV push
B. Use an infusion pump
C. Mix potassium with blood products
D. Administer undiluted potassium
Answer: B. Use an infusion pump
Rationale: IV potassium must be diluted and administered using a controlled
infusion pump. IV push potassium can cause fatal cardiac dysrhythmias.
10. Which laboratory result should the nurse monitor most closely in a client
receiving warfarin?
A. aPTT
B. INR
C. Serum amylase
D. Troponin
Answer: B. INR
Rationale: INR is used to monitor the therapeutic effect of warfarin and
assess the risk of bleeding.
11. A client receiving digoxin has an apical pulse of 52/min. What should the
nurse do?
A. Administer the medication
B. Hold the medication and notify the provider
C. Give an additional dose
D. Recheck the pulse after exercise
Answer: B. Hold the medication and notify the provider
Rationale: Bradycardia can indicate digoxin toxicity. The nurse should
withhold the medication and notify the provider.
12. Which electrolyte imbalance increases the risk of digoxin toxicity?
Practice Exam 3 100 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 immediate intervention?
A. Temperature of 37.2°C (99°F)
B. Blood pressure of 128/76 mm Hg
C. Chills and low back pain
D. Pulse of 84/min
Answer: C. Chills and low back pain
Rationale: Chills 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. Which laboratory value should the nurse report immediately for a client
receiving heparin therapy?
A. Hemoglobin 13.2 g/dL
B. Platelet count 48,000/mm³
C. Sodium 138 mEq/L
D. Potassium 4.2 mEq/L
Answer: B. Platelet count 48,000/mm³
,Rationale: A markedly decreased platelet count may indicate heparin-induced
thrombocytopenia (HIT), which increases the risk of thrombosis and requires
prompt intervention.
3. A client is scheduled for a lumbar puncture. Which assessment finding
should the nurse report before the procedure?
A. Headache rated 3/10
B. Blood pressure of 124/78 mm Hg
C. Platelet count of 45,000/mm³
D. Temperature of 37°C (98.6°F)
Answer: C. Platelet count of 45,000/mm³
Rationale: Severe thrombocytopenia increases the risk of bleeding during
lumbar puncture and may require postponement of the procedure.
4. A nurse is monitoring a client after thyroidectomy. Which finding requires
immediate action?
A. Hoarse voice
B. Mild incisional pain
C. Stridor
D. Sore throat
Answer: C. Stridor
Rationale: Stridor indicates possible airway obstruction from edema,
bleeding, or laryngeal complications. Airway compromise is an emergency.
5. Which assessment finding is most concerning in a client receiving
magnesium sulfate?
A. Respiratory rate of 10/min
B. Urine output of 45 mL/hr
C. Patellar reflexes 2+
D. Blood pressure of 140/88 mm Hg
Answer: A. Respiratory rate of 10/min
,Rationale: Respiratory depression is a sign of magnesium toxicity. The
infusion should be stopped and calcium gluconate should be available as the
antidote.
6. A nurse is caring for a client with a central venous catheter. Which finding
suggests a catheter-related infection?
A. Clear dressing
B. Temperature of 39°C (102.2°F)
C. Blood pressure of 118/72 mm Hg
D. Catheter flushing easily
Answer: B. Temperature of 39°C (102.2°F)
Rationale: Fever in a client with a central venous catheter may indicate
bloodstream infection and requires prompt assessment and intervention.
7. A client with a chest tube suddenly develops severe dyspnea. The nurse
notes that the drainage system has become disconnected. What should the
nurse do first?
A. Clamp the chest tube
B. Place the end of the tube in sterile water
C. Remove the chest tube
D. Apply a dry dressing
Answer: B. Place the end of the tube in sterile water
Rationale: Placing the disconnected chest tube end in sterile water
temporarily restores a water seal and helps prevent air from entering the
pleural space.
8. Which finding indicates that a chest tube may be functioning improperly?
A. Tidaling in the water-seal chamber
B. Intermittent bubbling with coughing
C. Continuous vigorous bubbling in the water-seal chamber
D. Drainage of 50 mL during the first hour
Answer: C. Continuous vigorous bubbling in the water-seal chamber
, Rationale: Continuous bubbling may indicate an air leak in the system or from
the client. The nurse should assess the tubing and connections.
9. A client is receiving potassium chloride intravenously. Which nursing action
is appropriate?
A. Administer potassium by IV push
B. Use an infusion pump
C. Mix potassium with blood products
D. Administer undiluted potassium
Answer: B. Use an infusion pump
Rationale: IV potassium must be diluted and administered using a controlled
infusion pump. IV push potassium can cause fatal cardiac dysrhythmias.
10. Which laboratory result should the nurse monitor most closely in a client
receiving warfarin?
A. aPTT
B. INR
C. Serum amylase
D. Troponin
Answer: B. INR
Rationale: INR is used to monitor the therapeutic effect of warfarin and
assess the risk of bleeding.
11. A client receiving digoxin has an apical pulse of 52/min. What should the
nurse do?
A. Administer the medication
B. Hold the medication and notify the provider
C. Give an additional dose
D. Recheck the pulse after exercise
Answer: B. Hold the medication and notify the provider
Rationale: Bradycardia can indicate digoxin toxicity. The nurse should
withhold the medication and notify the provider.
12. Which electrolyte imbalance increases the risk of digoxin toxicity?
