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 is two hours post thoracentesis of the right pleural space. Which assessment findings should prompt the nurse to suspect a complication and notify the provider? Select all that apply.
- A.Sudden sharp chest pain with shortness of breath
- B.Absent breath sounds over the right upper lung field
- C.Oxygen saturation dropping from 96% to 88% on room air
- D.Respiratory rate of 16 breaths per minute and unlabored breathing
- E.A small dry dressing over the puncture site
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Correct answers: A, B, C
After a needle enters the pleural space, the complication to watch for is pneumothorax, so trust cues of worsening gas exchange and a collapsing lung. Sudden sharp chest pain with dyspnea, newly absent breath sounds over a lung field, and a falling oxygen saturation all signal that air has entered the pleural space and the lung is not expanding. A normal unlabored respiratory rate and a clean dry dressing are reassuring findings that do not indicate a complication.
Why the other options are wrong
- D. A normal, unlabored respiratory rate reflects adequate ventilation, not a complication.
- E. A small dry dressing is an expected, reassuring post-procedure finding.
Key takeaway: After thoracentesis, sudden chest pain, absent breath sounds, and a dropping oxygen saturation point to pneumothorax.
A nurse reviews morning labs for a client receiving warfarin therapy. The international normalized ratio (INR) is 5.2. Which actions are appropriate? Select all that apply.
- A.Hold the next scheduled warfarin dose
- B.Notify the provider of the elevated INR
- C.Assess the client for signs of bleeding
- D.Administer an extra dose of warfarin to stabilize the level
- E.Keep vitamin K available in case the provider orders it
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Correct answers: A, B, C, E
When an anticoagulant level is too high, stop adding to it, look for harm, and tell the prescriber. A therapeutic INR for most clients is about 2 to 3, so 5.2 is supratherapeutic and raises bleeding risk. Hold the next dose, assess for bleeding such as bruising, gums, or hematuria, and notify the provider. Vitamin K is the reversal agent for warfarin, so keeping it available is prudent. Giving more warfarin would push the INR even higher and is unsafe.
Why the other options are wrong
- D. Tempting as a way to 'stabilize,' but more warfarin raises an already dangerous INR and increases bleeding risk.
Key takeaway: A supratherapeutic INR calls for holding the dose, assessing for bleeding, notifying the provider, and readying vitamin K.
Immediately after a large-volume paracentesis removing 5 liters of ascitic fluid, a client becomes lightheaded with a blood pressure of 88/52 mm Hg and a heart rate of 112/min. What is the nurse's priority action?
- A.Lower the head of the bed, ensure IV access, and notify the provider
- B.Encourage the client to ambulate to restore circulation
- C.Resume oral intake of solid food immediately
- D.Apply a warm compress to the puncture site
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Correct answer: A
Removing a large volume of ascitic fluid can trigger fluid shifts that drop intravascular volume, so new hypotension with tachycardia and lightheadedness signals hypovolemia. The priority is to support perfusion and prepare for treatment: lower the head of the bed to improve cerebral blood flow, confirm IV access for fluids or albumin, and notify the provider. Ambulating an unstable, hypotensive client risks a fall. Food and a warm compress do nothing for the circulatory problem.
Why the other options are wrong
- B. Ambulating a hypotensive, lightheaded client risks syncope and injury.
- C. Oral food does not correct acute intravascular volume loss.
- D. A warm compress addresses neither the hypotension nor the volume shift.
Key takeaway: After large-volume paracentesis, new hypotension and tachycardia signal hypovolemia; support perfusion and notify the provider.
A nurse is caring for a client during the first hours after a lumbar puncture. Which nursing actions are appropriate? Select all that apply.
- A.Keep the client lying flat as ordered
- B.Encourage increased fluid intake unless contraindicated
- C.Monitor the puncture site for drainage or hematoma
- D.Assess movement and sensation in the lower extremities
- E.Have the client sit upright in a chair right away to promote comfort
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Correct answers: A, B, C, D
Post-lumbar-puncture care targets two risks: a spinal (post-dural-puncture) headache from CSF leak and complications at the site. Lying flat and pushing fluids help maintain CSF volume and prevent or ease the headache. Checking the site catches bleeding or leakage, and assessing lower-extremity movement and sensation screens for neurologic injury. Sitting the client upright early increases the pressure gradient for CSF leak and can provoke the very headache you are trying to prevent. So all but sitting up apply.
Why the other options are wrong
- E. Sitting upright too soon promotes CSF leak and a post-dural-puncture headache.
Key takeaway: After a lumbar puncture, keep the client flat, push fluids, and monitor the site and neurologic status.
A nurse receives an arterial blood gas for a client with a small-bowel obstruction and prolonged nasogastric suctioning: pH 7.50, PaCO2 42 mm Hg, HCO3 32 mEq/L. Which interpretations and expected cues should the nurse anticipate? Select all that apply.
- A.The ABG shows metabolic alkalosis
- B.Loss of gastric acid through nasogastric suction is a likely cause
- C.The nurse should monitor for hypokalemia
- D.The ABG shows respiratory acidosis
- E.The client may report numbness, tingling, and muscle cramps
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Correct answers: A, B, C, E
Read the ABG in order: pH 7.50 is alkalemic, and the elevated HCO3 of 32 matches it while PaCO2 is normal, so this is metabolic alkalosis. Prolonged NG suction strips out hydrochloric acid, a classic cause. Alkalosis drives potassium into cells and promotes renal potassium loss, so watch for hypokalemia, and the lowered ionized calcium produces neuromuscular irritability: numbness, tingling, and cramps. It is not respiratory acidosis, since pH and CO2 don't fit that pattern.
Why the other options are wrong
- D. Respiratory acidosis would show a low pH with high CO2; here the pH is high and CO2 is normal.
Key takeaway: High pH with elevated bicarbonate is metabolic alkalosis; NG suction is a classic cause and risks hypokalemia and neuromuscular irritability.
A client has a chest tube connected to a water-seal drainage system after a thoracotomy. The nurse notes continuous, vigorous bubbling in the water-seal chamber. What should the nurse do first?
- A.Assess the tubing and connections from the client to the chamber for a loose connection
- B.Clamp the chest tube near the insertion site
- C.Document the bubbling as an expected finding and continue monitoring
- D.Increase the wall suction to clear the leak
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Correct answer: A
Continuous bubbling in the water-seal chamber means air is entering the system, so before assuming a problem in the lung, rule out the easy, fixable cause: an external air leak. Start at the client and trace the tubing and every connection toward the chamber, tightening or taping anything loose. Clamping a chest tube risks a tension pneumothorax and is not done for an air leak. Bubbling here is not expected continuously, and raising suction does not seal a leak.
Why the other options are wrong
- B. Clamping traps air and can cause a tension pneumothorax; never clamp to troubleshoot a leak.
- C. Continuous water-seal bubbling is abnormal and signals an air leak, not an expected finding.
- D. More suction does not fix a leak and can worsen air entrainment.
Key takeaway: For continuous water-seal bubbling, first trace the tubing for an external air leak before suspecting the lung.
A nurse watching the cardiac monitor sees a client suddenly show a wide, chaotic, irregular waveform with no identifiable QRS complexes. The client is unresponsive and has no pulse. What is the nurse's priority action?
- A.Begin high-quality chest compressions and call for the defibrillator
- B.Administer a beta blocker as ordered for rate control
- C.Prepare the client for synchronized cardioversion
- D.Reposition the monitor leads to confirm the tracing
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Correct answer: A
Treat the client, not the monitor: a chaotic waveform with no QRS in a pulseless, unresponsive client is ventricular fibrillation, a shockable arrest. The priority is to start chest compressions immediately and get the defibrillator, because early CPR plus defibrillation drives survival. Rate-control drugs are irrelevant in arrest. Synchronized cardioversion needs an organized rhythm to sync to; VF has none, so it is defibrillated, not cardioverted. Checking leads wastes time when the client is clearly pulseless.
Why the other options are wrong
- B. A beta blocker has no role in cardiac arrest and delays lifesaving care.
- C. Cardioversion requires an organized rhythm; pulseless VF is defibrillated, not synchronized.
- D. A pulseless, unresponsive client needs CPR now, not lead troubleshooting.
Key takeaway: Pulseless ventricular fibrillation calls for immediate CPR and defibrillation, never rate control or cardioversion.
A client returns to the unit after a liver biopsy. Which position should the nurse place the client in immediately after the procedure?
- A.On the right side with a small pillow against the biopsy site
- B.On the left side with the head of the bed flat
- C.High Fowler's with the legs dependent
- D.Prone with the arms above the head
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Correct answer: A
After a liver biopsy, the biggest risk is bleeding from the highly vascular liver, so position to apply pressure over the site. Place the client on the right side with a pillow or rolled towel pressed against the puncture, which tamponades the liver against the chest wall and limits hemorrhage. Left-side, high Fowler's, and prone positions all fail to compress the right-sided site. So right lateral with pressure is the protective choice.
Why the other options are wrong
- B. Lying on the left side leaves the right-sided puncture uncompressed.
- C. High Fowler's applies no pressure to the biopsy site.
- D. Prone positioning does not tamponade the liver and is uncomfortable post-procedure.
Key takeaway: After a liver biopsy, position the client right side-lying with pressure on the site to control bleeding.
A nurse is monitoring a client receiving moderate (procedural) sedation for an endoscopy. Which findings should prompt the nurse to intervene immediately? Select all that apply.
- A.Oxygen saturation drops to 86 percent on room air
- B.Respiratory rate falls to 7 breaths per minute
- C.The client responds purposefully to verbal commands
- D.The client becomes unresponsive to physical stimulation
- E.Blood pressure rises slightly from 122/74 to 128/80 mm Hg
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Correct answers: A, B, D
The danger of moderate sedation is slipping too deep, losing the airway and breathing, so intervene for any sign of respiratory compromise or oversedation. A saturation of 86 percent is hypoxemia, a rate of 7 is respiratory depression, and unresponsiveness to physical stimulation means the client has dropped below moderate sedation into a deeper, unsafe level. Purposeful response to voice is the goal of moderate sedation, and a trivial blood pressure rise is not concerning. So A, B, and D require action.
Why the other options are wrong
- C. Purposeful response to verbal commands defines an appropriate level of moderate sedation.
- E. A minor blood pressure increase within normal limits is not a danger sign.
Key takeaway: During moderate sedation, intervene for hypoxemia, respiratory depression, or loss of response to stimulation.
A nurse is providing preoperative teaching to a client scheduled for abdominal surgery. Which instruction best helps the client prevent postoperative pulmonary complications?
- A."Use the incentive spirometer and take deep breaths every hour while you are awake."
- B."Stay flat in bed and avoid moving until your incision heals."
- C."Limit how deeply you breathe so you don't strain the incision."
- D."Drink as little fluid as possible to keep your lungs from filling."
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Correct answer: A
Postoperative pulmonary complications stem from shallow breathing and immobility that let alveoli collapse, so teaching aims to keep the lungs inflated and the client moving. Using the incentive spirometer with hourly deep breathing while awake reopens alveoli and clears secretions, the core prevention. Staying flat and still promotes atelectasis, restricting breaths defeats the purpose, and limiting fluids thickens secretions. So hourly spirometry and deep breathing is the right instruction.
Why the other options are wrong
- B. Immobility and lying flat promote atelectasis; early mobility is encouraged.
- C. Shallow breathing causes the very alveolar collapse you want to prevent.
- D. Fluid restriction thickens secretions and does not protect the lungs.
Key takeaway: Hourly incentive spirometry with deep breathing prevents postoperative atelectasis and pneumonia.