NCLEX-RN Reduction of Risk Potential
Marathon (2025/2026) – Verified Questions &
Answers for Complete Risk Mitigation, Safety
Mastery, and NCLEX®-RN® Excellence
Question 1:
A nurse is caring for a patient receiving a blood transfusion. The patient develops chills, fever,
and back pain 15 minutes after initiation. What is the priority nursing action?
A. Stop the transfusion immediately
B. Slow the transfusion
C. Administer acetaminophen
D. Notify the physician after completing transfusion
Answer: A. Stop the transfusion immediately
Rationale: These are signs of a hemolytic transfusion reaction, which is life-threatening.
Immediate cessation of the transfusion is critical to prevent further complications.
Question 2:
A patient with a central venous catheter develops redness, swelling, and tenderness at the
insertion site. What is the priority action?
A. Remove the catheter and notify the provider
B. Apply warm compresses and monitor
C. Flush the catheter with saline
D. Administer prophylactic antibiotics
Answer: A. Remove the catheter and notify the provider
Rationale: Localized infection at a central line site can rapidly become systemic. Immediate
removal and provider notification are essential to reduce risk.
,Question 3:
A nurse is caring for a patient who has a history of falls. Which intervention most effectively
reduces fall risk?
A. Ensure the call light is within reach and educate patient on its use
B. Apply wrist restraints
C. Encourage the patient to walk alone to maintain independence
D. Keep the bed in high position
Answer: A. Ensure the call light is within reach and educate patient on its use
Rationale: Patient education and accessibility of the call light are evidence-based interventions
to reduce falls while maintaining safety. Restraints and high beds increase risk.
Question 4:
A patient with COPD is on oxygen therapy at 3 L/min. The nurse notices the patient appears
drowsy and confused. What should the nurse do first?
A. Assess the patient’s respiratory status and oxygen saturation
B. Increase oxygen to 5 L/min
C. Encourage deep breathing exercises
D. Document findings and reassess in 30 minutes
Answer: A. Assess the patient’s respiratory status and oxygen saturation
Rationale: COPD patients may retain CO₂; sudden drowsiness may indicate CO₂ retention or
hypoxia. Immediate assessment guides safe interventions.
Question 5:
A patient postoperatively develops sudden shortness of breath, chest pain, and tachycardia.
Which intervention is the priority?
A. Administer oxygen and notify the provider immediately
B. Reposition the patient in bed
C. Encourage coughing and deep breathing
D. Apply anti-embolism stockings
Answer: A. Administer oxygen and notify the provider immediately
Rationale: These are signs of a possible pulmonary embolism. Rapid oxygenation and provider
notification are critical to prevent deterioration.
, Question 6:
A patient on multiple medications reports dizziness and near-fainting upon standing. What is
the priority nursing intervention?
A. Assess for orthostatic hypotension
B. Encourage the patient to stand quickly
C. Restrict fluids
D. Schedule a follow-up in 1 week
Answer: A. Assess for orthostatic hypotension
Rationale: Orthostatic hypotension increases fall risk. Immediate assessment allows
interventions such as safety measures, medication adjustments, and patient education.
Question 7:
A patient scheduled for surgery is taking anticoagulants. Which action reduces the risk of
perioperative bleeding?
A. Hold anticoagulant medication as ordered preoperatively
B. Administer an extra dose of anticoagulant
C. Encourage vigorous physical activity
D. Delay lab tests
Answer: A. Hold anticoagulant medication as ordered preoperatively
Rationale: Following provider instructions for holding anticoagulants minimizes surgical
bleeding risk. Unsupervised dose changes increase risk.
Question 8:
A patient with impaired mobility is at risk for pressure ulcers. Which intervention is most
effective in prevention?
A. Reposition the patient every 2 hours
B. Apply a heating pad to the affected area
C. Encourage the patient to remain in one position
D. Limit fluid intake
Answer: A. Reposition the patient every 2 hours
Rationale: Frequent repositioning reduces pressure on bony prominences, preventing skin
breakdown. Heating pads and immobility increase risk.
Marathon (2025/2026) – Verified Questions &
Answers for Complete Risk Mitigation, Safety
Mastery, and NCLEX®-RN® Excellence
Question 1:
A nurse is caring for a patient receiving a blood transfusion. The patient develops chills, fever,
and back pain 15 minutes after initiation. What is the priority nursing action?
A. Stop the transfusion immediately
B. Slow the transfusion
C. Administer acetaminophen
D. Notify the physician after completing transfusion
Answer: A. Stop the transfusion immediately
Rationale: These are signs of a hemolytic transfusion reaction, which is life-threatening.
Immediate cessation of the transfusion is critical to prevent further complications.
Question 2:
A patient with a central venous catheter develops redness, swelling, and tenderness at the
insertion site. What is the priority action?
A. Remove the catheter and notify the provider
B. Apply warm compresses and monitor
C. Flush the catheter with saline
D. Administer prophylactic antibiotics
Answer: A. Remove the catheter and notify the provider
Rationale: Localized infection at a central line site can rapidly become systemic. Immediate
removal and provider notification are essential to reduce risk.
,Question 3:
A nurse is caring for a patient who has a history of falls. Which intervention most effectively
reduces fall risk?
A. Ensure the call light is within reach and educate patient on its use
B. Apply wrist restraints
C. Encourage the patient to walk alone to maintain independence
D. Keep the bed in high position
Answer: A. Ensure the call light is within reach and educate patient on its use
Rationale: Patient education and accessibility of the call light are evidence-based interventions
to reduce falls while maintaining safety. Restraints and high beds increase risk.
Question 4:
A patient with COPD is on oxygen therapy at 3 L/min. The nurse notices the patient appears
drowsy and confused. What should the nurse do first?
A. Assess the patient’s respiratory status and oxygen saturation
B. Increase oxygen to 5 L/min
C. Encourage deep breathing exercises
D. Document findings and reassess in 30 minutes
Answer: A. Assess the patient’s respiratory status and oxygen saturation
Rationale: COPD patients may retain CO₂; sudden drowsiness may indicate CO₂ retention or
hypoxia. Immediate assessment guides safe interventions.
Question 5:
A patient postoperatively develops sudden shortness of breath, chest pain, and tachycardia.
Which intervention is the priority?
A. Administer oxygen and notify the provider immediately
B. Reposition the patient in bed
C. Encourage coughing and deep breathing
D. Apply anti-embolism stockings
Answer: A. Administer oxygen and notify the provider immediately
Rationale: These are signs of a possible pulmonary embolism. Rapid oxygenation and provider
notification are critical to prevent deterioration.
, Question 6:
A patient on multiple medications reports dizziness and near-fainting upon standing. What is
the priority nursing intervention?
A. Assess for orthostatic hypotension
B. Encourage the patient to stand quickly
C. Restrict fluids
D. Schedule a follow-up in 1 week
Answer: A. Assess for orthostatic hypotension
Rationale: Orthostatic hypotension increases fall risk. Immediate assessment allows
interventions such as safety measures, medication adjustments, and patient education.
Question 7:
A patient scheduled for surgery is taking anticoagulants. Which action reduces the risk of
perioperative bleeding?
A. Hold anticoagulant medication as ordered preoperatively
B. Administer an extra dose of anticoagulant
C. Encourage vigorous physical activity
D. Delay lab tests
Answer: A. Hold anticoagulant medication as ordered preoperatively
Rationale: Following provider instructions for holding anticoagulants minimizes surgical
bleeding risk. Unsupervised dose changes increase risk.
Question 8:
A patient with impaired mobility is at risk for pressure ulcers. Which intervention is most
effective in prevention?
A. Reposition the patient every 2 hours
B. Apply a heating pad to the affected area
C. Encourage the patient to remain in one position
D. Limit fluid intake
Answer: A. Reposition the patient every 2 hours
Rationale: Frequent repositioning reduces pressure on bony prominences, preventing skin
breakdown. Heating pads and immobility increase risk.
