NCLEX-RN Reduction of
Risk Potential Updated 2025
(19 Questions)
Question 1:
Which risk factors for a positive result of the stool for occult blood (OB) test should the
nurse recognize? (Select all that apply.)
A) Recent teeth cleaning at the dentist office
B) Use of naproxen sodium for pain relief
C) Eating a steak dinner the night before
D) Recent use of corticosteroids
E) History of a colonoscopy two years ago
F) Family history of colon cancer
Answer:
A) Recent teeth cleaning at the dentist office
B) Use of naproxen sodium for pain relief
C) Eating a steak dinner the night before
D) Recent use of corticosteroids
Explanation:
Occult blood (OB) testing of the stool is used for colorectal cancer screening or to detect occult
blood from other causes such as gastric or duodenal ulcers, diverticulosis, or gastrointestinal (GI)
bleeding. Drugs that can cause GI bleeding include NSAIDs such as ibuprofen and naproxen
(Aleve). Corticosteroids can cause gastric irritation, including peptic ulcers that can also lead to
GI bleeding. Factors that may cause a false positive result include bleeding gums following a
dental procedure and the ingestion of red meats within three days before testing because red
meats contain animal hemoglobin.
Question 2:
Which lab test is the most sensitive measure of nutritional status for an 80-year-old client
with unintentional weight loss and a diagnosis of malnutrition?
, A) Serum albumin
B) Urine creatinine
C) Urine protein
D) Serum calcium
Answer:
A) Serum albumin
Explanation:
Serum albumin is the most sensitive measure of nutritional status, as its levels reflect the body's
protein stores. Low serum albumin levels are commonly seen in clients with malnutrition,
making it a key indicator.
Question 3:
Rank the interventions the nurse should perform from first to last for a client in the post-
anesthesia care unit (PACU) with vital signs indicating hypovolemia (T = 98 F, pulse = 115,
respirations = 14, BP = 82/46 mm Hg, cold and clammy skin).
A) Elevate the lower extremities
B) Assess the surgical dressing
C) Assess the area dependent to the surgical incision
D) Increase the intravenous (IV) rate
E) Reassess vital signs
Answer:
1. D) Increase the intravenous (IV) rate
2. A) Elevate the lower extremities
3. B) Assess the surgical dressing
4. C) Assess the area dependent to the surgical incision
5. E) Reassess vital signs
Explanation:
The client is exhibiting signs of hypovolemia, and the first intervention should be to increase the
IV rate to maintain circulatory volume. Elevating the lower extremities helps bring fluid from the
lower body to the core. Afterward, the nurse should assess the surgical dressing and the area
dependent to the incision to ensure there is no bleeding. Reassessing vital signs is necessary to
evaluate the effectiveness of these interventions.
Risk Potential Updated 2025
(19 Questions)
Question 1:
Which risk factors for a positive result of the stool for occult blood (OB) test should the
nurse recognize? (Select all that apply.)
A) Recent teeth cleaning at the dentist office
B) Use of naproxen sodium for pain relief
C) Eating a steak dinner the night before
D) Recent use of corticosteroids
E) History of a colonoscopy two years ago
F) Family history of colon cancer
Answer:
A) Recent teeth cleaning at the dentist office
B) Use of naproxen sodium for pain relief
C) Eating a steak dinner the night before
D) Recent use of corticosteroids
Explanation:
Occult blood (OB) testing of the stool is used for colorectal cancer screening or to detect occult
blood from other causes such as gastric or duodenal ulcers, diverticulosis, or gastrointestinal (GI)
bleeding. Drugs that can cause GI bleeding include NSAIDs such as ibuprofen and naproxen
(Aleve). Corticosteroids can cause gastric irritation, including peptic ulcers that can also lead to
GI bleeding. Factors that may cause a false positive result include bleeding gums following a
dental procedure and the ingestion of red meats within three days before testing because red
meats contain animal hemoglobin.
Question 2:
Which lab test is the most sensitive measure of nutritional status for an 80-year-old client
with unintentional weight loss and a diagnosis of malnutrition?
, A) Serum albumin
B) Urine creatinine
C) Urine protein
D) Serum calcium
Answer:
A) Serum albumin
Explanation:
Serum albumin is the most sensitive measure of nutritional status, as its levels reflect the body's
protein stores. Low serum albumin levels are commonly seen in clients with malnutrition,
making it a key indicator.
Question 3:
Rank the interventions the nurse should perform from first to last for a client in the post-
anesthesia care unit (PACU) with vital signs indicating hypovolemia (T = 98 F, pulse = 115,
respirations = 14, BP = 82/46 mm Hg, cold and clammy skin).
A) Elevate the lower extremities
B) Assess the surgical dressing
C) Assess the area dependent to the surgical incision
D) Increase the intravenous (IV) rate
E) Reassess vital signs
Answer:
1. D) Increase the intravenous (IV) rate
2. A) Elevate the lower extremities
3. B) Assess the surgical dressing
4. C) Assess the area dependent to the surgical incision
5. E) Reassess vital signs
Explanation:
The client is exhibiting signs of hypovolemia, and the first intervention should be to increase the
IV rate to maintain circulatory volume. Elevating the lower extremities helps bring fluid from the
lower body to the core. Afterward, the nurse should assess the surgical dressing and the area
dependent to the incision to ensure there is no bleeding. Reassessing vital signs is necessary to
evaluate the effectiveness of these interventions.
