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EDAPT: NCLEX Readiness: Reduction of
Risk Potential Questions and Answers Latest
Update
Click to specify the nursing actions that will help reduce the risk of
complications for this client and the actions that would produce greater
complications for this client. Select one option per row. Ans: Reduces Risk
of Complications:
▸ Assist the client with ambulation using a walker.
▸ Consult with a speech therapist about the use of adding thickening agents
to water and other oral liquids.
▸ Place absorbent pads on top of the fitted sheet in the bed.
▸ Assist the client in making position changes in the bed or chair at least
every 2 hours.
Increases Risk of Complications:
▸ Stand on the client's left side when assisting with ambulation.
▸ Request a prescription for an indwelling urinary catheter.
▸ Place a donut cushion under the client's bottom when seated in the
wheelchair.
The nurse develops a teaching plan for a client having an upcoming total
knee arthroplasty. What information should the nurse include in the
preoperative teaching to promote health and reduce the risk of
© 2025 All rights reserved
, 2 | Page
complications? Select all that apply. Ans: ▸ "The provider will prescribe a
stool softener for you to take while you are taking pain medication."
▸ "It is important for you to perform deep breathing exercises and cough
several times an hour when you're awake for a few weeks after the surgery."
▸ "Make sure to cleanse your knee with the 2% chlorohexidine wipes the
night before surgery and the morning of surgery."
The nurse cares for a client in the intensive care unit who is on a mechanical
ventilator, has a triple-lumen central venous access device (CVAD), and a
urinary catheter. For each treatment device, identify the nursing actions to
include in the plan of care to reduce the risk of complications. Select one or
more answers related to nursing care for each device. Ans: Mechanical
Ventilator:
1. Routinely clean the client's mouth with chlorhexidine solutions.
2. Elevate the head of the bed at least 30 degrees.
3. Turn the client every 2 hours.
4. Pause sedation at least once per 24 hours.
Central Venous Access Device (CVAD):
2. Use a 10 mL syringe when flushing or giving medications.
3. Assess for compatibility before putting more than one agent in a line
together.
4. Place a mask on the client and wear one as the nurse during dressing
changes.
Urinary Catheter:
© 2025 All rights reserved
, 3 | Page
2. Maintain bag below level of pelvis.
3. Perform peri-care every shift and after bowel movements.
4. Empty the drainage bag every few hours or when 2/3 full.
Click to specify the steps of the procedure that the observing nurse should
question and those that indicate the procedure nurse completed the
prescribed procedure correctly. Ans: Observing Nurse Should Question:
▸ Opened all supplies using clean gloves
▸ Donned clean gloves to cleanse the area with chlorhexidine swab sticks
before switching to sterile gloves for insertion
▸ Secured the catheter to the client's inner thigh after insertion as the urine
drains into the collection container
Procedure Nurse Performed Correctly:
▸ Cleaned the perineal area with soap and water prior to the procedure
▸ Removed the catheter from the bladder after collecting the amount
needed
▸ Labeled the urine specimen container with the client's initials, date of
birth, date and time of the collection, route used for specimen collection,
and nurse's initials
The nurse is assessing a stable client with fluid imbalance concerns. The
nurse reviews the electronic health record and finds this information:
What actions should the nurse take first? Select all that apply. Ans: ▸ Verify
the cuff size.
▸ Recheck the client's blood pressure.
© 2025 All rights reserved
, 4 | Page
The nurse admits a client into the triage area and reviews the client's vital
signs.
Based on the client's trends in vital signs, the nurse is initially the most
concerned with the __________ and should anticipate a prescription for the
priority intervention, which is to __________. Ans: ▸ Oxygen saturation
▸ Administer oxygen
The nurse admits an older adult client to the medical-surgical unit with a
suspected urinary tract infection. The hospital policy is for two nurses to
complete an admission skin assessment. Highlight the sections in the
nursing note that put the client at an increased risk for skin breakdown.
Ans: ▸ Diabetes
▸ Neuropathy
▸ Peripheral vascular disease
▸ Cool to touch in distal extremities
▸ Non-blanchable redness noted above the client's sacrum
▸ Bruise noted on right lower calf
▸ She does not feel it
▸ Urinary incontinence
A client is admitted to a long-term care facility due to inability to remain
independent with activities of daily living. The client had a fall 6 weeks ago
and, while no bones were fractured, the client experienced pain and
discomfort that limited mobility after the fall. The client's adult child is
present at the start of the admission and reports the client has "been in bed
for most of the last month." Which questions should the nurse ask to assess
the client's risk of complications associated with prolonged immobility?
© 2025 All rights reserved
EDAPT: NCLEX Readiness: Reduction of
Risk Potential Questions and Answers Latest
Update
Click to specify the nursing actions that will help reduce the risk of
complications for this client and the actions that would produce greater
complications for this client. Select one option per row. Ans: Reduces Risk
of Complications:
▸ Assist the client with ambulation using a walker.
▸ Consult with a speech therapist about the use of adding thickening agents
to water and other oral liquids.
▸ Place absorbent pads on top of the fitted sheet in the bed.
▸ Assist the client in making position changes in the bed or chair at least
every 2 hours.
Increases Risk of Complications:
▸ Stand on the client's left side when assisting with ambulation.
▸ Request a prescription for an indwelling urinary catheter.
▸ Place a donut cushion under the client's bottom when seated in the
wheelchair.
The nurse develops a teaching plan for a client having an upcoming total
knee arthroplasty. What information should the nurse include in the
preoperative teaching to promote health and reduce the risk of
© 2025 All rights reserved
, 2 | Page
complications? Select all that apply. Ans: ▸ "The provider will prescribe a
stool softener for you to take while you are taking pain medication."
▸ "It is important for you to perform deep breathing exercises and cough
several times an hour when you're awake for a few weeks after the surgery."
▸ "Make sure to cleanse your knee with the 2% chlorohexidine wipes the
night before surgery and the morning of surgery."
The nurse cares for a client in the intensive care unit who is on a mechanical
ventilator, has a triple-lumen central venous access device (CVAD), and a
urinary catheter. For each treatment device, identify the nursing actions to
include in the plan of care to reduce the risk of complications. Select one or
more answers related to nursing care for each device. Ans: Mechanical
Ventilator:
1. Routinely clean the client's mouth with chlorhexidine solutions.
2. Elevate the head of the bed at least 30 degrees.
3. Turn the client every 2 hours.
4. Pause sedation at least once per 24 hours.
Central Venous Access Device (CVAD):
2. Use a 10 mL syringe when flushing or giving medications.
3. Assess for compatibility before putting more than one agent in a line
together.
4. Place a mask on the client and wear one as the nurse during dressing
changes.
Urinary Catheter:
© 2025 All rights reserved
, 3 | Page
2. Maintain bag below level of pelvis.
3. Perform peri-care every shift and after bowel movements.
4. Empty the drainage bag every few hours or when 2/3 full.
Click to specify the steps of the procedure that the observing nurse should
question and those that indicate the procedure nurse completed the
prescribed procedure correctly. Ans: Observing Nurse Should Question:
▸ Opened all supplies using clean gloves
▸ Donned clean gloves to cleanse the area with chlorhexidine swab sticks
before switching to sterile gloves for insertion
▸ Secured the catheter to the client's inner thigh after insertion as the urine
drains into the collection container
Procedure Nurse Performed Correctly:
▸ Cleaned the perineal area with soap and water prior to the procedure
▸ Removed the catheter from the bladder after collecting the amount
needed
▸ Labeled the urine specimen container with the client's initials, date of
birth, date and time of the collection, route used for specimen collection,
and nurse's initials
The nurse is assessing a stable client with fluid imbalance concerns. The
nurse reviews the electronic health record and finds this information:
What actions should the nurse take first? Select all that apply. Ans: ▸ Verify
the cuff size.
▸ Recheck the client's blood pressure.
© 2025 All rights reserved
, 4 | Page
The nurse admits a client into the triage area and reviews the client's vital
signs.
Based on the client's trends in vital signs, the nurse is initially the most
concerned with the __________ and should anticipate a prescription for the
priority intervention, which is to __________. Ans: ▸ Oxygen saturation
▸ Administer oxygen
The nurse admits an older adult client to the medical-surgical unit with a
suspected urinary tract infection. The hospital policy is for two nurses to
complete an admission skin assessment. Highlight the sections in the
nursing note that put the client at an increased risk for skin breakdown.
Ans: ▸ Diabetes
▸ Neuropathy
▸ Peripheral vascular disease
▸ Cool to touch in distal extremities
▸ Non-blanchable redness noted above the client's sacrum
▸ Bruise noted on right lower calf
▸ She does not feel it
▸ Urinary incontinence
A client is admitted to a long-term care facility due to inability to remain
independent with activities of daily living. The client had a fall 6 weeks ago
and, while no bones were fractured, the client experienced pain and
discomfort that limited mobility after the fall. The client's adult child is
present at the start of the admission and reports the client has "been in bed
for most of the last month." Which questions should the nurse ask to assess
the client's risk of complications associated with prolonged immobility?
© 2025 All rights reserved
