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These practice questions target NCLEX-PN level complexity for the subject '''Reduction of Risk Potential''': accurate data collection, recognition of findings outside expected parameters, correct performance of standard pre-procedure and post-procedure care, and prompt, specific reporting to the registered nurse or provider. Items marked ''select all that apply'' have more than one correct option. Always follow the facility policy and the state nurse practice act that define the licensed practical or vocational nurse scope of practice.

==Question 1==
A licensed practical nurse takes vital signs on a client who is one day postoperative from abdominal surgery. Which finding should be reported to the registered nurse immediately?
# Oral temperature 37.6 degrees Celsius (99.7 degrees Fahrenheit)
# Blood pressure 86/48 mm Hg with a heart rate of 122 beats per minute
# Respiratory rate 18 breaths per minute
# Oxygen saturation 96 percent on room air

'''Answer:''' Option 2. Blood pressure 86/48 mm Hg with a heart rate of 122 beats per minute.

''Rationale:'' Hypotension with tachycardia in a postoperative client suggests hemorrhage or hypovolemia and must be reported at once. Option 1 is a mildly elevated temperature that is common in the first postoperative day and is usually related to atelectasis; it should be documented and reported routinely but is not the immediate priority. Options 3 and 4 are within expected ranges.

==Question 2==
The nurse is caring for a client whose laboratory report shows a serum potassium of 2.9 mEq/L. Which assessment finding should the nurse expect and report?
# Muscle weakness and hypoactive bowel sounds
# Increased deep tendon reflexes and muscle spasm
# Bounding peripheral pulses and hypertension
# Warm flushed skin and a strong appetite

'''Answer:''' Option 1. Muscle weakness and hypoactive bowel sounds.

''Rationale:'' The normal serum potassium is 3.5 to 5.0 mEq/L, so 2.9 mEq/L is hypokalemia. Low potassium reduces neuromuscular excitability, producing generalized weakness, leg cramps, decreased deep tendon reflexes, and slowed gastrointestinal motility that can progress to paralytic ileus. Cardiac dysrhythmias are the most dangerous consequence. Options 2, 3, and 4 do not describe hypokalemia.

==Question 3==
''Select all that apply.'' Which vital sign findings in an adult client should the nurse report to the registered nurse as outside expected parameters?
# Heart rate 48 beats per minute in a client receiving metoprolol
# Respiratory rate 9 breaths per minute in a client receiving morphine
# Temperature 36.8 degrees Celsius (98.2 degrees Fahrenheit)
# Oxygen saturation 88 percent on room air
# Blood pressure 118/76 mm Hg

'''Answer:''' Options 1, 2, and 4.

''Rationale:'' An adult heart rate below 60 beats per minute in a client on a beta blocker signals excessive rate control and requires reporting before the next dose. A respiratory rate below 12 in a client receiving an opioid signals respiratory depression and is urgent. An oxygen saturation of 88 percent is significant hypoxemia. Options 3 and 5 fall within normal ranges and require documentation only.

==Question 4==
A client is scheduled for an esophagogastroduodenoscopy with moderate sedation. Immediately after the procedure, which nursing action is most important?
# Offer the client ice chips to soothe the throat.
# Keep the client nothing by mouth until the gag reflex has returned.
# Ambulate the client in the hallway to prevent atelectasis.
# Apply a warm compress to the throat.

'''Answer:''' Option 2. Keep the client nothing by mouth until the gag reflex has returned.

''Rationale:'' A topical anesthetic is used to numb the throat, and the gag reflex must return before anything is given by mouth or the client can aspirate. The nurse checks the gag reflex per policy before offering fluids. Options 1 and 4 risk aspiration or are ineffective, and option 3 is unsafe while the client is still sedated.

==Question 5==
The nurse is preparing a client for a paracentesis. Which action should the nurse take before the procedure?
# Position the client flat on the back with the legs elevated.
# Ask the client to void immediately before the procedure.
# Give the client a large glass of water to fill the bladder.
# Withhold all pain medication for 24 hours beforehand.

'''Answer:''' Option 2. Ask the client to void immediately before the procedure.

''Rationale:'' Emptying the bladder reduces the risk of accidental bladder puncture when the abdominal wall is entered. The client is usually positioned upright or with the head of the bed elevated so that fluid collects in the lower abdomen. Options 1 and 3 increase risk, and option 4 is not required.

==Question 6==
A client who had a liver biopsy two hours ago reports increasing abdominal pain and pain in the right shoulder. Blood pressure is 92/58 mm Hg and the heart rate is 116 beats per minute. What should the nurse do?
# Reposition the client onto the left side and reassess in one hour.
# Report the findings to the registered nurse immediately and keep the client on bed rest.
# Encourage the client to walk to relieve the gas pain.
# Offer the client a heating pad for the shoulder.

'''Answer:''' Option 2. Report the findings to the registered nurse immediately and keep the client on bed rest.

''Rationale:'' The liver is highly vascular, and hemorrhage is the major complication of liver biopsy. Increasing abdominal pain, referred right shoulder pain, hypotension, and tachycardia together suggest bleeding and require immediate reporting. The client remains on bed rest, usually positioned on the right side to apply pressure to the biopsy site. Options 1, 3, and 4 delay recognition of a life-threatening complication.

==Question 7==
The nurse is caring for a client receiving a unit of packed red blood cells. Fifteen minutes into the transfusion the client develops hives, itching, and reports feeling flushed. What should the nurse do first?
# Stop the transfusion and keep the intravenous line open with normal saline.
# Slow the rate and give the client an antihistamine that was ordered as needed.
# Apply lotion to the skin and continue the transfusion.
# Take the client's temperature and document the finding.

'''Answer:''' Option 1. Stop the transfusion and keep the intravenous line open with normal saline.

''Rationale:'' Any suspected transfusion reaction requires stopping the transfusion first, then maintaining the intravenous line with normal saline through new tubing so that no more blood enters, and notifying the registered nurse, provider, and blood bank. Assessment and medication follow after the transfusion is stopped. Options 2 and 3 continue exposure to the product. Option 4 delays the priority action, although vital signs are obtained right after stopping.

==Question 8==
''Select all that apply.'' Which actions are appropriate when the nurse is caring for a client with a peripheral intravenous infusion?
# Assess the site for swelling, coolness, and pallor that suggest infiltration.
# Assess the site for redness, warmth, and a palpable cord that suggest phlebitis.
# Massage a reddened, painful intravenous site vigorously to improve circulation.
# Report a sudden decrease in the infusion rate along with the client's report of site discomfort.
# Continue the infusion at the ordered rate if the site is swollen but the client denies pain.

'''Answer:''' Options 1, 2, and 4.

''Rationale:'' Infiltration produces cool, pale, swollen tissue with a sluggish rate, and phlebitis produces redness, warmth, tenderness, and a cord-like vein; both require discontinuing the site. Option 3 can worsen inflammation and dislodge a clot. Option 5 is unsafe, because infiltration can occur without pain, especially in older adults and in clients with reduced sensation, and continuing the infusion damages tissue.

==Question 9==
A client returned from a cardiac catheterization through the right femoral artery one hour ago. Which finding requires immediate reporting to the registered nurse?
# The client reports mild soreness at the insertion site.
# The right foot is cool and pale, and the pedal pulse cannot be palpated.
# The client is drowsy but easily arousable.
# The client reports needing to urinate.

'''Answer:''' Option 2. The right foot is cool and pale, and the pedal pulse cannot be palpated.

''Rationale:'' A cool, pale extremity with an absent distal pulse suggests arterial occlusion or a compromising hematoma at the access site and is a limb-threatening emergency. Option 1 is expected. Option 3 is consistent with recent sedation. Option 4 is a normal need that the nurse assists with while keeping the leg straight and the client on bed rest.

==Question 10==
The nurse is collecting a 24-hour urine specimen. Which action is correct?
# Save the first voiding at the start of the collection period.
# Discard the first voiding, then collect all urine for the next 24 hours, ending with a final voiding at the exact end time.
# Collect only the daytime voidings and estimate the overnight volume.
# Store the container at room temperature in the client's bathroom.

'''Answer:''' Option 2. Discard the first voiding, then collect all urine for the next 24 hours, ending with a final voiding at the exact end time.

''Rationale:'' The bladder must be empty when timing starts, so the first specimen is discarded and the clock begins. Every subsequent voiding is saved, and the client is asked to void at the exact end time so that specimen is included. If any voiding is accidentally discarded, the collection must be restarted. The container is usually kept refrigerated or on ice as required by the laboratory, which makes option 4 incorrect.

==Question 11==
A client scheduled for magnetic resonance imaging tells the nurse about several items. Which statement requires the nurse to notify the registered nurse before the client goes to the scanner?
# "I had a metal fragment go into my eye at work years ago and I do not know if it was removed."
# "I have a plastic hip protector I wear over my clothing."
# "I get a little anxious in small spaces but I have done this before."
# "I ate a light breakfast this morning."

'''Answer:''' Option 1. The report of a possible retained metal fragment in the eye.

''Rationale:'' A retained ferromagnetic fragment can move within the magnetic field and cause serious injury, so the imaging team must screen and clear the client, often with a radiograph, before scanning. Option 2 is removable and not implanted. Option 3 should be communicated so support or a mild anxiolytic can be considered, but it is not a safety contraindication. Option 4 matters only if the specific study requires fasting.

==Question 12==
A client had a barium swallow study this morning. Which instruction should the nurse reinforce?
# "Avoid fluids for the rest of the day so the barium stays in place."
# "Drink extra fluids and take the laxative that was ordered; your stools will look chalky white for a few days."
# "Report bright red stools immediately, since that is caused by the barium."
# "Stay on bed rest until the barium is fully absorbed into your bloodstream."

'''Answer:''' Option 2. Drink extra fluids and take the ordered laxative, and expect chalky white stools for a few days.

''Rationale:'' Barium hardens in the bowel and can cause constipation or impaction, so fluids and a laxative are used to clear it, and light-colored stools are expected temporarily. Option 1 promotes impaction. Option 3 is inaccurate, since barium lightens stool rather than causing bright red blood, and bright red stool would indicate bleeding. Option 4 is incorrect because barium is not absorbed systemically and mobility helps elimination.

==Question 13==
''Select all that apply.'' Which findings in a postoperative client should the nurse report to the registered nurse promptly?
# The client reports that the abdominal incision "feels like something gave way," and a sudden increase in serosanguineous drainage is noted.
# Urine output of 15 mL over the past hour in an adult with an indwelling catheter.
# The calf of one leg is swollen, warm, and painful.
# The client used the incentive spirometer ten times in the last hour.
# The client rates incision pain as 3 out of 10 after receiving the ordered analgesic.

'''Answer:''' Options 1, 2, and 3.

''Rationale:'' A sensation that something gave way with a gush of serosanguineous drainage often precedes wound dehiscence and requires immediate reporting. Adult urine output below roughly 30 mL per hour signals inadequate renal perfusion. Unilateral calf swelling, warmth, and pain suggest deep vein thrombosis, and the leg must not be massaged. Option 4 is a desirable behavior, and option 5 shows effective pain control.

==Question 14==
A client's abdominal wound eviscerates while the nurse is changing the dressing. What should the nurse do first?
# Push the tissue back into the abdomen and apply a dry dressing.
# Cover the exposed tissue with sterile gauze moistened with sterile normal saline, position the client supine with the knees slightly flexed, and call for help.
# Assist the client to sit upright in a chair and give oral fluids.
# Leave the client to obtain sterile supplies from the clean utility room.

'''Answer:''' Option 2. Cover the exposed tissue with sterile gauze moistened with sterile normal saline, position the client supine with the knees slightly flexed, and call for help.

''Rationale:'' Moist sterile coverage prevents drying and damage of the exposed viscera, and supine positioning with flexed knees reduces tension on the abdominal wall. The client is kept nothing by mouth in anticipation of surgery, monitored for shock, and never left alone. Option 1 can cause injury and contamination. Option 3 increases abdominal pressure and violates nothing by mouth status. Option 4 leaves the client unattended; the nurse calls for help instead.

==Question 15==
The nurse reviews the morning laboratory report for four assigned clients. Which value should be reported to the registered nurse first?
# Hemoglobin 11.6 g/dL in a client with chronic anemia
# Serum sodium 138 mEq/L
# Serum potassium 6.2 mEq/L in a client with chronic kidney disease
# Fasting blood glucose 122 mg/dL in a client with type 2 diabetes

'''Answer:''' Option 3. Serum potassium 6.2 mEq/L in a client with chronic kidney disease.

''Rationale:'' The normal potassium range is 3.5 to 5.0 mEq/L, and a value of 6.2 mEq/L is dangerous hyperkalemia that can cause fatal cardiac dysrhythmias, so it is reported first. Option 1 is a mildly low hemoglobin consistent with a known chronic condition. Option 2 is normal. Option 4 is mildly elevated and expected in diabetes; it is documented and reported routinely, not urgently.

[[Category:Reduction of Risk Potential]]
[[Category:Licensed Practical Nurse (NCLEX-PN)]]
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