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 client is prescribed warfarin (Coumadin). Which lab result requires immediate nursing
action?
A. INR 1.2
B. PT 18 sec (normal 11–13.5 sec)
C. Platelet count 300,000/mm³
D. Hemoglobin 13 g/dL
Answer: B. PT 18 sec. Rationale: Elevated PT indicates increased bleeding risk with
warfarin and requires intervention.
2. A nurse finds a confused client trying to get out of bed unassisted. The nurse’s best
immediate action is to:
A. Apply soft wrist restraints.
B. Remind family to stay with client.
C. Assist client to a chair and stay with them.
D. Give a PRN sedative.
Answer: C. Assist client to a chair and stay with them. Rationale: Immediate safety
and supervision reduce fall risk without restraints or sedatives.
,3. A client on heparin infusion has an aPTT of 120 sec (therapeutic 60–80 sec). Nurse
should:
A. Increase infusion rate.
B. Hold infusion and notify provider.
C. Obtain PT/INR.
D. Document and continue.
Answer: B. Hold infusion and notify provider. Rationale: Elevated aPTT indicates
bleeding risk; hold and consult provider.
4. A medication administration error occurs but no harm to the client. Nurse must:
A. Hide the error if client is stable.
B. Report the error per facility policy and complete incident report.
C. Tell client’s family only.
D. Wait to see if client develops symptoms.
Answer: B. Report error and complete incident report. Rationale: Ethical and legal
duty to report errors; incident reporting required.
5. A client has a new prescription for metformin and is scheduled for CT scan with contrast.
Nurse should:
A. Administer metformin as usual.
B. Hold metformin 48 hours after contrast per policy.
C. Double the metformin dose.
D. Substitute glipizide.
Answer: B. Hold metformin 48 hours after contrast. Rationale: Contrast can cause
renal impairment leading to lactic acidosis with metformin.
6. Which finding in a post-op client indicates possible pulmonary embolism?
A. Gradual temperature of 100.2°F.
B. Sudden chest pain and dyspnea.
C. Incisional redness.
D. Mild ankle swelling.
Answer: B. Sudden chest pain and dyspnea. Rationale: These are classic PE signs
and require emergency response.
7. A nurse preparing to insert an indwelling urinary catheter should:
A. Use sterile technique.
B. Use clean gloves only.
C. Rinse catheter with tap water.
D. Delegate insertion to UAP.
Answer: A. Use sterile technique. Rationale: Sterile technique prevents CAUTI.
8. A client receives potassium IV bolus too rapidly and becomes bradycardic. Immediate
action:
A. Document and monitor.
, B. Stop infusion and call provider.
C. Administer furosemide.
D. Increase infusion rate of normal saline.
Answer: B. Stop infusion and call provider. Rationale: Rapid IV potassium can cause
life-threatening arrhythmia; stop immediately.
9. A patient allergic to penicillin needs antibiotic. Best action:
A. Administer cephalosporin without checking.
B. Ask about reaction type before giving any beta-lactam.
C. Give penicillin test dose.
D. Give vancomycin regardless.
Answer: B. Ask about reaction type. Rationale: Clarify allergy severity due to
cross-reactivity; then consult provider.
10.A client with NG tube feeding has sudden respiratory distress and coughing after
feeding. Nurse should:
A. Stop feeding and assess for aspiration.
B. Increase feeding rate.
C. Continue feeding after repositioning.
D. Give bronchodilator.
Answer: A. Stop feeding and assess for aspiration. Rationale: Respiratory distress
suggests aspiration; stop and evaluate.
11.Prior to giving digoxin, nurse should check:
A. Serum sodium.
B. Apical pulse for 1 full minute.
C. Blood glucose.
D. Respiratory rate.
Answer: B. Apical pulse for 1 full minute. Rationale: Bradycardia is contraindication;
apical pulse check required.
12.A client with altered mental status is at highest risk for:
A. Infection.
B. Falls and aspiration.
C. Hyperactivity.
D. Hypertension.
Answer: B. Falls and aspiration. Rationale: Confusion increases risk of falling and
aspiration.
13.When caring for a client with MRSA, the nurse should:
A. Use airborne precautions.
B. Use contact precautions (gown and gloves).
C. No precautions needed.
D. Place in negative-pressure room.
, Answer: B. Contact precautions. Rationale: MRSA transmitted by contact; gown and
gloves required.
14.A client starts showing signs of transfusion reaction (flank pain, fever). Nurse should:
A. Slow the transfusion rate.
B. Stop transfusion immediately and notify provider.
C. Finish transfusion and document.
D. Give antihistamine and continue.
Answer: B. Stop transfusion immediately. Rationale: Suspected transfusion reaction
— stop, keep IV open with NS, notify.
15.A newly licensed nurse is assigned a drowning victim. Which tasks should be delegated
to unlicensed assistive personnel (UAP)?
A. Initiating CPR.
B. Starting IV fluids.
C. Measuring and recording vital signs after stabilization.
D. Intubation.
Answer: C. Measuring and recording vital signs after stabilization. Rationale: UAP
may record VS; advanced tasks reserved for licensed staff.
16.A client with neutropenia should avoid:
A. Fresh fruit and flowers.
B. Prepared deli meats.
C. Bottled water.
D. Well-cooked eggs.
Answer: A. Fresh fruit and flowers. Rationale: They can carry bacteria; neutropenic
clients need low-microbial diet/environment.
17.Which is best to prevent catheter-associated urinary tract infections (CAUTI)?
A. Routine catheter changes every 48 hours.
B. Remove catheter as soon as no longer needed.
C. Flush bladder daily.
D. Use prophylactic antibiotics.
Answer: B. Remove catheter ASAP. Rationale: Reducing catheter days lowers CAUTI
risk.
18.A client on high-dose steroids should be monitored for:
A. Hypoglycemia.
B. Hyperglycemia and infection risk.
C. Increased immune function.
D. Hypotension.
Answer: B. Hyperglycemia and infection risk. Rationale: Steroids raise blood
glucose and suppress immunity.
Exam (2025/2026) – Verified Questions &
Answers for Mastery-Level Risk Mitigation,
System-Wide Safety, and NCLEX®-RN®
Superiority
1. A client is prescribed warfarin (Coumadin). Which lab result requires immediate nursing
action?
A. INR 1.2
B. PT 18 sec (normal 11–13.5 sec)
C. Platelet count 300,000/mm³
D. Hemoglobin 13 g/dL
Answer: B. PT 18 sec. Rationale: Elevated PT indicates increased bleeding risk with
warfarin and requires intervention.
2. A nurse finds a confused client trying to get out of bed unassisted. The nurse’s best
immediate action is to:
A. Apply soft wrist restraints.
B. Remind family to stay with client.
C. Assist client to a chair and stay with them.
D. Give a PRN sedative.
Answer: C. Assist client to a chair and stay with them. Rationale: Immediate safety
and supervision reduce fall risk without restraints or sedatives.
,3. A client on heparin infusion has an aPTT of 120 sec (therapeutic 60–80 sec). Nurse
should:
A. Increase infusion rate.
B. Hold infusion and notify provider.
C. Obtain PT/INR.
D. Document and continue.
Answer: B. Hold infusion and notify provider. Rationale: Elevated aPTT indicates
bleeding risk; hold and consult provider.
4. A medication administration error occurs but no harm to the client. Nurse must:
A. Hide the error if client is stable.
B. Report the error per facility policy and complete incident report.
C. Tell client’s family only.
D. Wait to see if client develops symptoms.
Answer: B. Report error and complete incident report. Rationale: Ethical and legal
duty to report errors; incident reporting required.
5. A client has a new prescription for metformin and is scheduled for CT scan with contrast.
Nurse should:
A. Administer metformin as usual.
B. Hold metformin 48 hours after contrast per policy.
C. Double the metformin dose.
D. Substitute glipizide.
Answer: B. Hold metformin 48 hours after contrast. Rationale: Contrast can cause
renal impairment leading to lactic acidosis with metformin.
6. Which finding in a post-op client indicates possible pulmonary embolism?
A. Gradual temperature of 100.2°F.
B. Sudden chest pain and dyspnea.
C. Incisional redness.
D. Mild ankle swelling.
Answer: B. Sudden chest pain and dyspnea. Rationale: These are classic PE signs
and require emergency response.
7. A nurse preparing to insert an indwelling urinary catheter should:
A. Use sterile technique.
B. Use clean gloves only.
C. Rinse catheter with tap water.
D. Delegate insertion to UAP.
Answer: A. Use sterile technique. Rationale: Sterile technique prevents CAUTI.
8. A client receives potassium IV bolus too rapidly and becomes bradycardic. Immediate
action:
A. Document and monitor.
, B. Stop infusion and call provider.
C. Administer furosemide.
D. Increase infusion rate of normal saline.
Answer: B. Stop infusion and call provider. Rationale: Rapid IV potassium can cause
life-threatening arrhythmia; stop immediately.
9. A patient allergic to penicillin needs antibiotic. Best action:
A. Administer cephalosporin without checking.
B. Ask about reaction type before giving any beta-lactam.
C. Give penicillin test dose.
D. Give vancomycin regardless.
Answer: B. Ask about reaction type. Rationale: Clarify allergy severity due to
cross-reactivity; then consult provider.
10.A client with NG tube feeding has sudden respiratory distress and coughing after
feeding. Nurse should:
A. Stop feeding and assess for aspiration.
B. Increase feeding rate.
C. Continue feeding after repositioning.
D. Give bronchodilator.
Answer: A. Stop feeding and assess for aspiration. Rationale: Respiratory distress
suggests aspiration; stop and evaluate.
11.Prior to giving digoxin, nurse should check:
A. Serum sodium.
B. Apical pulse for 1 full minute.
C. Blood glucose.
D. Respiratory rate.
Answer: B. Apical pulse for 1 full minute. Rationale: Bradycardia is contraindication;
apical pulse check required.
12.A client with altered mental status is at highest risk for:
A. Infection.
B. Falls and aspiration.
C. Hyperactivity.
D. Hypertension.
Answer: B. Falls and aspiration. Rationale: Confusion increases risk of falling and
aspiration.
13.When caring for a client with MRSA, the nurse should:
A. Use airborne precautions.
B. Use contact precautions (gown and gloves).
C. No precautions needed.
D. Place in negative-pressure room.
, Answer: B. Contact precautions. Rationale: MRSA transmitted by contact; gown and
gloves required.
14.A client starts showing signs of transfusion reaction (flank pain, fever). Nurse should:
A. Slow the transfusion rate.
B. Stop transfusion immediately and notify provider.
C. Finish transfusion and document.
D. Give antihistamine and continue.
Answer: B. Stop transfusion immediately. Rationale: Suspected transfusion reaction
— stop, keep IV open with NS, notify.
15.A newly licensed nurse is assigned a drowning victim. Which tasks should be delegated
to unlicensed assistive personnel (UAP)?
A. Initiating CPR.
B. Starting IV fluids.
C. Measuring and recording vital signs after stabilization.
D. Intubation.
Answer: C. Measuring and recording vital signs after stabilization. Rationale: UAP
may record VS; advanced tasks reserved for licensed staff.
16.A client with neutropenia should avoid:
A. Fresh fruit and flowers.
B. Prepared deli meats.
C. Bottled water.
D. Well-cooked eggs.
Answer: A. Fresh fruit and flowers. Rationale: They can carry bacteria; neutropenic
clients need low-microbial diet/environment.
17.Which is best to prevent catheter-associated urinary tract infections (CAUTI)?
A. Routine catheter changes every 48 hours.
B. Remove catheter as soon as no longer needed.
C. Flush bladder daily.
D. Use prophylactic antibiotics.
Answer: B. Remove catheter ASAP. Rationale: Reducing catheter days lowers CAUTI
risk.
18.A client on high-dose steroids should be monitored for:
A. Hypoglycemia.
B. Hyperglycemia and infection risk.
C. Increased immune function.
D. Hypotension.
Answer: B. Hyperglycemia and infection risk. Rationale: Steroids raise blood
glucose and suppress immunity.
