Free NCLEX-RN Reduction of Risk Potential Questions
Free NCLEX-RN reduction of risk potential practice questions with rationales — lab values, diagnostics, and complication monitoring.
A client has dysphagia (difficulty swallowing) after a stroke. Which measures should the nurse use to reduce the risk of aspiration? Select all that apply.
Correct answers: o1, o2, o3, o5
To lower aspiration risk with dysphagia, the client sits fully upright, tucks the chin while swallowing (which helps close the airway), takes thickened liquids and small bites, and is given time to swallow between bites. Thin liquids and straws increase the risk of liquid slipping into the airway, and eating quickly while lying back is dangerous.
Why the other options are wrong
- o4. Offering thin liquids through a straw is contraindicated because straws deliver a fast, concentrated stream of fluid directly to the posterior pharynx. This rapid volume exceeds the client's ability to coordinate airway closure, significantly increasing the risk of aspiration. Key distinction: Thickened liquids are given by spoon or cup, which allows the client to control the bolus size.
- o6. Eating quickly or while lying back removes the protective effect of gravity and makes it easier for food or fluid to slide into the open airway before the epiglottis closes. This posture also increases the risk of gastroesophageal reflux and subsequent aspiration. Key distinction: Reclined positions are contraindicated for meals; the client must remain upright at 90 degrees during and after eating.
Key takeaway: Dysphagia: sit fully upright, chin-tuck, thickened liquids, small bites, and time to swallow; avoid thin liquids and straws.
Which actions help prevent aspiration in a client receiving enteral tube feedings? Select all that apply.
Correct answers: o1, o2, o3, o5
Preventing aspiration during tube feeding includes keeping the head of the bed elevated at least 30 degrees, verifying tube placement, checking residual as ordered, and keeping the head elevated for 30 to 60 minutes after a bolus feeding. Lying flat right after feeding and giving feedings too quickly both increase aspiration risk.
Why the other options are wrong
- o4. Lying flat immediately after a feeding eliminates the gravitational barrier that prevents gastric reflux. Key distinction: The head of the bed must remain elevated for 30 to 60 minutes after a bolus feeding to allow the stomach to empty.
- o6. Rapidly infusing enteral formula distends the stomach too quickly, triggering nausea, vomiting, and reflux. Key distinction: Feedings must be administered at the prescribed rate via gravity drip or electronic pump to ensure safe gastric emptying.
Key takeaway: Tube-feeding aspiration prevention: head elevated, verify placement, check residual, stay upright after feeds.
A postoperative client's urine output has been 20 mL/hr for the last 2 hours. Which is the priority action?
Correct answer: C
A urine output below about 30 mL/hr suggests inadequate kidney perfusion and possible hypovolemia or acute kidney injury, so the nurse notifies the provider and assesses fluid status. Documenting it as normal ignores a warning sign, ambulation does not address low output, and withholding fluids worsens the low perfusion.
Why the other options are wrong
- A. Urine output below 30 mL/hr indicates oliguria and must not be documented as normal. Ignoring this finding delays the identification of acute kidney injury or shock.
- B. Ambulation does not restore systemic perfusion to the kidneys in a hypovolemic client. The priority is to assess fluid volume and notify the provider for potential IV fluid resuscitation.
- D. Adequate circulating volume is necessary to maintain renal perfusion. Withholding fluids reduces blood flow to the kidneys and accelerates acute tubular necrosis.
Key takeaway: Urine output under 30 mL/hr is a warning sign: notify the provider and assess fluid status.
A client's chemotherapy has caused severe neutropenia. Which instructions should the nurse include for infection precautions at home? Select all that apply.
Correct answers: o1, o2, o3, o4
With severe neutropenia the client cannot fight infection, so precautions focus on avoiding exposure: stay away from crowds and sick people, report a fever promptly (it may be the only sign of infection), avoid fresh flowers and raw produce that carry organisms, and perform frequent hand hygiene. Daily aspirin does not prevent fever and raises bleeding risk, and flossing after every meal can cause gum trauma that lets bacteria enter the bloodstream.
Why the other options are wrong
- o5. Taking aspirin can mask an early fever, delaying the recognition and treatment of life-threatening neutropenic sepsis, and it also impairs platelet aggregation, increasing the risk of bleeding. Key distinction: Fever is a vital warning sign that must be reported immediately, not suppressed with antipyretics.
- o6. Flossing can cause micro-tears in the fragile gums, creating a direct portal of entry for oral bacteria into the bloodstream of an immunocompromised client. Key distinction: While oral hygiene is vital to prevent stomatitis, gentle rinsing and soft-bristled brushing are preferred over flossing to minimize mechanical trauma.
Key takeaway: Neutropenia: avoid crowds, sick people, flowers, and raw produce; wash hands; and report any fever at once.
A client's chemotherapy has caused thrombocytopenia. Which instructions should the nurse include for bleeding precautions? Select all that apply.
Correct answers: o1, o2, o3, o4
A low platelet count means the client bleeds easily, so precautions reduce trauma and detect bleeding: shave with an electric razor, use a soft toothbrush and avoid flossing, avoid aspirin and NSAIDs that impair clotting, and report signs of internal bleeding such as tarry stools or bloody urine. Frequent nose blowing can trigger a nosebleed, and a rectal thermometer can tear the fragile lining and cause bleeding.
Why the other options are wrong
- o5. Blowing the nose forcefully creates high pressure that easily ruptures the fragile capillary networks in the nasal mucosa, leading to epistaxis that is difficult to control. Key distinction: The nasal passages should be kept moist with saline sprays and gently patted rather than blown.
- o6. Inserting a thermometer or probe into the rectum can easily tear the highly vascular rectal mucosa, causing significant and hard-to-detect internal hemorrhage. Key distinction: Temperature measurement must be restricted to oral, axillary, or tympanic routes to avoid mucosal trauma.
Key takeaway: Thrombocytopenia: electric razor, soft toothbrush, no aspirin or NSAIDs, no rectal route, and report tarry stools or bloody urine.
A multiparous client has just had a precipitous birth, with total labor lasting under 3 hours. For which complication should the nurse most closely monitor in the immediate postpartum period?
Correct answer: B
A very rapid labor gives the uterus little chance to contract in a coordinated way and forces the fetus through the birth canal quickly, so the uterus may fail to clamp down (atony) and the tissues can tear. Both drive postpartum hemorrhage, which is the immediate priority. Endometritis is a real complication but appears on postpartum day two to three, bladder distention from regional anesthesia and thromboembolism from immobility are important but not the earliest life threat, and none of the three matches the timing and severity of atony-related bleeding right after birth.
Why the other options are wrong
- A. Endometritis is an infection of the uterine lining that presents with fever, foul-smelling lochia, and uterine tenderness. Key distinction: This infectious complication typically manifests 24 to 72 hours postpartum, whereas uterine atony and lacerations present as immediate, life-threatening hemorrhages in the minutes following birth.
- C. Bladder distention is common postpartum, especially if the client received regional anesthesia, and can displace the uterus. Key distinction: Although a full bladder can cause uterine displacement and bleeding, active hemorrhage from atony or lacerations is a direct, immediate cardiovascular threat that must be addressed first.
- D. Deep vein thrombosis is a vascular complication related to pregnancy-induced hypercoagulability and immobility. Key distinction: Thrombotic events develop over days or weeks and require long-term prevention, whereas maternal hemorrhage from atony or lacerations is an acute emergency occurring within minutes of delivery.
Key takeaway: After a precipitous birth, watch closely for postpartum hemorrhage from uterine atony and lacerations.
Which instructions should the nurse include for a client after cataract surgery? Select all that apply.
Correct answers: o1, o2, o4, o5
After cataract surgery the client wears an eye shield (especially at night), avoids bending, heavy lifting, and straining (which raise eye pressure), and reports sudden pain or vision loss (possible complication). The client does not rub the eye and avoids lying on the operative side, which puts pressure on the healing eye.
Why the other options are wrong
- o3. Rubbing the eye exerts direct mechanical force on the delicate corneal incision, which can open the wound, displace the intraocular lens, or introduce bacteria. Key distinction: Itching should be treated with prescribed eye drops, and the eye must remain untouched.
- o6. Sleeping on the operative side puts direct pressure on the healing eye, which can increase intraocular pressure and disrupt the incision. Key distinction: Clients must sleep on their back or on the unaffected side to keep the surgical site pressure-free.
Key takeaway: Post-cataract care: eye shield, avoid bending/lifting/straining and rubbing, do not lie on the operative side, and report pain or vision loss.
The nurse is monitoring a client receiving intravenous ondansetron for nausea. Which finding is most important to report to the provider?
Correct answer: D
Every finding here is abnormal, so the nurse must prioritize. Ondansetron can prolong the QT interval, which can trigger a fatal arrhythmia, so that is reported first. Orthostatic lightheadedness, two days without a stool, and a small rise in liver enzymes all warrant follow-up but none is immediately life-threatening.
Why the other options are wrong
- A. Orthostatic lightheadedness is a safety concern that requires slow position changes, but it is not a life-threatening conduction issue like QT prolongation.
- B. Constipation is a common side effect of 5-HT3 antagonists due to slowed colonic transit, but two days without a bowel movement is not an acute emergency.
- C. Transient elevations in liver transaminases can occur with ondansetron, but they are typically asymptomatic and do not take priority over an active cardiac risk. Key distinction: Conduction delays pose an immediate threat of sudden cardiac death, whereas liver enzyme shifts are slowly developing metabolic changes.
Key takeaway: Ondansetron can prolong the QT interval; a QT change outranks other abnormal but non-emergent findings.
The nurse is assessing a client 6 hours after a cesarean birth. Which finding requires the most immediate follow-up?
Correct answer: D
A boggy (soft) uterus with a pad saturated in 15 minutes signals uterine atony and active postpartum hemorrhage, which is the priority to act on immediately. A firm fundus at the umbilicus is the expected finding and incisional pain of 4 after medication is acceptable. Urine output of 25 mL per hour is a true abnormal cue that must be followed up, but it reflects developing hypovolemia or early kidney compromise and is a consequence of the bleeding rather than the source, so the hemorrhage takes precedence.
Why the other options are wrong
- A. A firm fundus located at the level of the umbilicus is a normal and expected finding six hours after birth. Key distinction: A firm uterus indicates that the uterine muscle is contracted and successfully compressing the bleeding blood vessels.
- B. A pain rating of 4 out of 10 after receiving pain medication is a typical postoperative finding. Key distinction: While pain should be managed, it is a non-urgent comfort issue that is secondary to hemodynamic stability.
- C. A urine output of less than 30 mL/hour is abnormal and may indicate dehydration, renal hypoperfusion, or a kinked catheter. Key distinction: Although this finding requires assessment and troubleshooting, active hemorrhage from an atonic uterus is an immediate life-threatening emergency that takes priority.
Key takeaway: After cesarean birth, a boggy uterus with heavy bleeding is the priority: it signals atony and hemorrhage.