NCLEX-RN Reduction of Risk Potential 4
Exam (2025/2026) – Verified Questions &
Answers for Mastery-Level Risk Mitigation,
System-Wide Safety, and NCLEX®-RN®
Superiority
1. A nurse is caring for a client receiving IV potassium chloride. Which finding requires
immediate intervention?
✅
A. Burning at the IV site
Answer: A
Rationale: Burning indicates possible extravasation or irritation — potassium is caustic to
veins.
2. The nurse notes a patient with a tracheostomy has gurgling sounds during inspiration. What
is the best action?
✅
A. Suction the tracheostomy tube
Answer: A
Rationale: Gurgling suggests secretion buildup; suctioning prevents airway obstruction.
3. The nurse prepares a client for a lumbar puncture. Which position is appropriate?
A. Lateral recumbent with knees to chest
,✅ Answer: A
Rationale: Flexing the spine widens intervertebral spaces for needle insertion.
4. Which assessment finding indicates early hypoxia?
✅
A. Restlessness
Answer: A
Rationale: Restlessness is an early sign of decreased oxygenation before cyanosis develops.
5. A postoperative client suddenly becomes short of breath with chest pain. First action?
✅
A. Elevate head of bed
Answer: A
Rationale: Promotes lung expansion and oxygenation while assessing further.
6. During blood transfusion, a client reports chills and fever. Nurse’s first action?
✅
A. Stop the transfusion
Answer: A
Rationale: Immediate cessation prevents further reaction or hemolysis.
7. Which lab result indicates risk for bleeding?
✅
A. Platelet count 90,000/mm³
Answer: A
Rationale: Thrombocytopenia increases bleeding risk.
8. The nurse notices continuous bubbling in the water-seal chamber of a chest tube. What does
this indicate?
✅
A. Air leak
Answer: A
Rationale: Continuous bubbling means air is escaping from the system.
9. Which action reduces risk for aspiration during enteral feeding?
✅
A. Elevate HOB to 30–45°
Answer: A
Rationale: Upright position prevents reflux and aspiration.
, 10. A client with renal failure reports muscle weakness. Which electrolyte imbalance is
suspected?
✅
A. Hyperkalemia
Answer: A
Rationale: High potassium affects neuromuscular function.
11. Which sign indicates infiltration at an IV site?
✅
A. Cool, pale skin
Answer: A
Rationale: Fluid leaks into tissue causing pallor and coolness.
12. The nurse must monitor which parameter most closely during magnesium sulfate therapy?
✅
A. Deep tendon reflexes
Answer: A
Rationale: Decreased reflexes suggest magnesium toxicity.
13. The most accurate way to confirm NG tube placement is:
✅
A. X-ray confirmation
Answer: A
Rationale: Radiographic verification is the gold standard.
14. A client receiving heparin has a PTT of 120 seconds. Nurse should:
✅
A. Hold the dose and notify provider
Answer: A
Rationale: Elevated PTT increases bleeding risk.
15. A postoperative client’s wound eviscerates. Priority action?
✅
A. Cover with sterile saline dressing
Answer: A
Rationale: Keeps organs moist and prevents infection.
Exam (2025/2026) – Verified Questions &
Answers for Mastery-Level Risk Mitigation,
System-Wide Safety, and NCLEX®-RN®
Superiority
1. A nurse is caring for a client receiving IV potassium chloride. Which finding requires
immediate intervention?
✅
A. Burning at the IV site
Answer: A
Rationale: Burning indicates possible extravasation or irritation — potassium is caustic to
veins.
2. The nurse notes a patient with a tracheostomy has gurgling sounds during inspiration. What
is the best action?
✅
A. Suction the tracheostomy tube
Answer: A
Rationale: Gurgling suggests secretion buildup; suctioning prevents airway obstruction.
3. The nurse prepares a client for a lumbar puncture. Which position is appropriate?
A. Lateral recumbent with knees to chest
,✅ Answer: A
Rationale: Flexing the spine widens intervertebral spaces for needle insertion.
4. Which assessment finding indicates early hypoxia?
✅
A. Restlessness
Answer: A
Rationale: Restlessness is an early sign of decreased oxygenation before cyanosis develops.
5. A postoperative client suddenly becomes short of breath with chest pain. First action?
✅
A. Elevate head of bed
Answer: A
Rationale: Promotes lung expansion and oxygenation while assessing further.
6. During blood transfusion, a client reports chills and fever. Nurse’s first action?
✅
A. Stop the transfusion
Answer: A
Rationale: Immediate cessation prevents further reaction or hemolysis.
7. Which lab result indicates risk for bleeding?
✅
A. Platelet count 90,000/mm³
Answer: A
Rationale: Thrombocytopenia increases bleeding risk.
8. The nurse notices continuous bubbling in the water-seal chamber of a chest tube. What does
this indicate?
✅
A. Air leak
Answer: A
Rationale: Continuous bubbling means air is escaping from the system.
9. Which action reduces risk for aspiration during enteral feeding?
✅
A. Elevate HOB to 30–45°
Answer: A
Rationale: Upright position prevents reflux and aspiration.
, 10. A client with renal failure reports muscle weakness. Which electrolyte imbalance is
suspected?
✅
A. Hyperkalemia
Answer: A
Rationale: High potassium affects neuromuscular function.
11. Which sign indicates infiltration at an IV site?
✅
A. Cool, pale skin
Answer: A
Rationale: Fluid leaks into tissue causing pallor and coolness.
12. The nurse must monitor which parameter most closely during magnesium sulfate therapy?
✅
A. Deep tendon reflexes
Answer: A
Rationale: Decreased reflexes suggest magnesium toxicity.
13. The most accurate way to confirm NG tube placement is:
✅
A. X-ray confirmation
Answer: A
Rationale: Radiographic verification is the gold standard.
14. A client receiving heparin has a PTT of 120 seconds. Nurse should:
✅
A. Hold the dose and notify provider
Answer: A
Rationale: Elevated PTT increases bleeding risk.
15. A postoperative client’s wound eviscerates. Priority action?
✅
A. Cover with sterile saline dressing
Answer: A
Rationale: Keeps organs moist and prevents infection.
