NCLEX RN Reduction of Risk Potential
Exam 5 100 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 the nurse to stop the transfusion immediately?
A. Temperature of 37.2°C (99°F)
B. Blood pressure of 138/82 mm Hg
C. Chills and low back pain
D. Heart rate of 88/min
Answer: Chills and low back pain
Rationale: Chills and low back pain may 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. A client is scheduled for a lumbar puncture. Which position should the
nurse assist the client into?
A. Prone with the head turned to the side
B. Side-lying with knees flexed toward the chest
C. Supine with the legs extended
D. High-Fowler's position
Answer: Side-lying with knees flexed toward the chest
,Rationale: Flexing the spine while the client is in a lateral position increases
the space between the vertebrae and facilitates insertion of the spinal
needle.
3. A client receiving potassium chloride IV develops muscle weakness and
an irregular heart rhythm. Which laboratory value should the nurse
suspect?
A. Sodium 140 mEq/L
B. Potassium 6.4 mEq/L
C. Calcium 9.2 mg/dL
D. Magnesium 2.0 mg/dL
Answer: Potassium 6.4 mEq/L
Rationale: A potassium level above approximately 5.0 mEq/L indicates
hyperkalemia. Severe hyperkalemia can cause muscle weakness and
potentially fatal cardiac dysrhythmias.
4. A nurse is monitoring a client after a thyroidectomy. Which finding
requires immediate intervention?
A. Hoarse voice
B. Mild incisional pain
C. Tingling around the mouth
D. Small amount of drainage on the dressing
Answer: Tingling around the mouth
Rationale: Perioral tingling may indicate hypocalcemia caused by accidental
removal or injury of the parathyroid glands. Severe hypocalcemia can
progress to tetany and laryngospasm.
5. A client with a central venous catheter suddenly develops dyspnea and
chest pain during catheter removal. Which complication should the
nurse suspect?
A. Pneumonia
B. Air embolism
C. Pulmonary edema
D. Atelectasis
,Answer: Air embolism
Rationale: Sudden dyspnea, chest pain, hypotension, or neurologic changes
during central-line removal can indicate an air embolism. The client should be
positioned appropriately and emergency measures initiated.
6. A client is receiving heparin therapy. Which laboratory test is primarily
used to monitor unfractionated heparin therapy?
A. INR
B. aPTT
C. Platelet count only
D. Hemoglobin A1c
Answer: aPTT
Rationale: The activated partial thromboplastin time is commonly used to
monitor the therapeutic effect of unfractionated heparin.
7. A client receiving warfarin has an INR of 5.8. Which action should the
nurse anticipate?
A. Administer the next dose immediately
B. Increase the warfarin dose
C. Hold warfarin and notify the provider
D. Administer potassium chloride
Answer: Hold warfarin and notify the provider
Rationale: An INR of 5.8 indicates excessive anticoagulation and an increased
risk of bleeding. Warfarin should be held and the provider notified for further
management.
8. A client with suspected increased intracranial pressure has which finding
that requires immediate attention?
A. Mild headache
B. Restlessness
C. Decreasing level of consciousness
D. Temperature of 37°C (98.6°F)
Answer: Decreasing level of consciousness
, Rationale: A decreasing level of consciousness is an important early indicator
of neurological deterioration and increased intracranial pressure.
9. A client is receiving digoxin. Which finding should cause the nurse to
withhold the medication and notify the provider?
A. Apical pulse of 54/min
B. Respiratory rate of 18/min
C. Blood pressure of 128/74 mm Hg
D. Temperature of 36.8°C (98.2°F)
Answer: Apical pulse of 54/min
Rationale: Digoxin can cause bradycardia. The medication is generally
withheld when the adult apical pulse is below 60/min unless otherwise
prescribed.
10.A client with chronic kidney disease has a potassium level of 6.7 mEq/L.
Which ECG finding should the nurse anticipate?
A. Flattened T waves
B. Peaked T waves
C. Prolonged QT interval
D. ST elevation only
Answer: Peaked T waves
Rationale: Hyperkalemia commonly produces tall, peaked T waves and may
progress to widened QRS complexes and life-threatening dysrhythmias.
11.A nurse is preparing a client for a CT scan with iodinated contrast. Which
assessment is most important?
A. Favorite foods
B. History of contrast allergy
C. Usual sleeping pattern
D. Last bowel movement
Answer: History of contrast allergy
Exam 5 100 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 the nurse to stop the transfusion immediately?
A. Temperature of 37.2°C (99°F)
B. Blood pressure of 138/82 mm Hg
C. Chills and low back pain
D. Heart rate of 88/min
Answer: Chills and low back pain
Rationale: Chills and low back pain may 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. A client is scheduled for a lumbar puncture. Which position should the
nurse assist the client into?
A. Prone with the head turned to the side
B. Side-lying with knees flexed toward the chest
C. Supine with the legs extended
D. High-Fowler's position
Answer: Side-lying with knees flexed toward the chest
,Rationale: Flexing the spine while the client is in a lateral position increases
the space between the vertebrae and facilitates insertion of the spinal
needle.
3. A client receiving potassium chloride IV develops muscle weakness and
an irregular heart rhythm. Which laboratory value should the nurse
suspect?
A. Sodium 140 mEq/L
B. Potassium 6.4 mEq/L
C. Calcium 9.2 mg/dL
D. Magnesium 2.0 mg/dL
Answer: Potassium 6.4 mEq/L
Rationale: A potassium level above approximately 5.0 mEq/L indicates
hyperkalemia. Severe hyperkalemia can cause muscle weakness and
potentially fatal cardiac dysrhythmias.
4. A nurse is monitoring a client after a thyroidectomy. Which finding
requires immediate intervention?
A. Hoarse voice
B. Mild incisional pain
C. Tingling around the mouth
D. Small amount of drainage on the dressing
Answer: Tingling around the mouth
Rationale: Perioral tingling may indicate hypocalcemia caused by accidental
removal or injury of the parathyroid glands. Severe hypocalcemia can
progress to tetany and laryngospasm.
5. A client with a central venous catheter suddenly develops dyspnea and
chest pain during catheter removal. Which complication should the
nurse suspect?
A. Pneumonia
B. Air embolism
C. Pulmonary edema
D. Atelectasis
,Answer: Air embolism
Rationale: Sudden dyspnea, chest pain, hypotension, or neurologic changes
during central-line removal can indicate an air embolism. The client should be
positioned appropriately and emergency measures initiated.
6. A client is receiving heparin therapy. Which laboratory test is primarily
used to monitor unfractionated heparin therapy?
A. INR
B. aPTT
C. Platelet count only
D. Hemoglobin A1c
Answer: aPTT
Rationale: The activated partial thromboplastin time is commonly used to
monitor the therapeutic effect of unfractionated heparin.
7. A client receiving warfarin has an INR of 5.8. Which action should the
nurse anticipate?
A. Administer the next dose immediately
B. Increase the warfarin dose
C. Hold warfarin and notify the provider
D. Administer potassium chloride
Answer: Hold warfarin and notify the provider
Rationale: An INR of 5.8 indicates excessive anticoagulation and an increased
risk of bleeding. Warfarin should be held and the provider notified for further
management.
8. A client with suspected increased intracranial pressure has which finding
that requires immediate attention?
A. Mild headache
B. Restlessness
C. Decreasing level of consciousness
D. Temperature of 37°C (98.6°F)
Answer: Decreasing level of consciousness
, Rationale: A decreasing level of consciousness is an important early indicator
of neurological deterioration and increased intracranial pressure.
9. A client is receiving digoxin. Which finding should cause the nurse to
withhold the medication and notify the provider?
A. Apical pulse of 54/min
B. Respiratory rate of 18/min
C. Blood pressure of 128/74 mm Hg
D. Temperature of 36.8°C (98.2°F)
Answer: Apical pulse of 54/min
Rationale: Digoxin can cause bradycardia. The medication is generally
withheld when the adult apical pulse is below 60/min unless otherwise
prescribed.
10.A client with chronic kidney disease has a potassium level of 6.7 mEq/L.
Which ECG finding should the nurse anticipate?
A. Flattened T waves
B. Peaked T waves
C. Prolonged QT interval
D. ST elevation only
Answer: Peaked T waves
Rationale: Hyperkalemia commonly produces tall, peaked T waves and may
progress to widened QRS complexes and life-threatening dysrhythmias.
11.A nurse is preparing a client for a CT scan with iodinated contrast. Which
assessment is most important?
A. Favorite foods
B. History of contrast allergy
C. Usual sleeping pattern
D. Last bowel movement
Answer: History of contrast allergy
