Reduction of Risk Potential – RN Practice Questions

These practice questions target NCLEX-RN level complexity for the subject Reduction of Risk Potential: interpreting abnormal laboratory and diagnostic results, anticipating and preventing complications, and prioritizing care. Items marked select all that apply have more than one correct option.

Question 1

A client with heart failure receives furosemide 40 mg orally daily and digoxin 0.125 mg orally daily. The morning laboratory report shows a serum potassium of 3.0 mEq/L and a digoxin level of 1.4 ng/mL. Which action should the nurse take first?

1. Administer the digoxin as scheduled because the level is within the therapeutic range.
2. Hold the digoxin, notify the provider of the potassium level, and obtain an apical pulse.
3. Encourage the client to increase dietary intake of bananas and orange juice.
4. Request an order to increase the furosemide dose to reduce fluid overload.

Answer: Option 2. Hold the digoxin, notify the provider of the potassium level, and obtain an apical pulse.

Rationale: Hypokalemia sensitizes the myocardium to digoxin, so a client can develop toxicity and life-threatening dysrhythmias even when the serum digoxin level appears therapeutic. The safe sequence is to withhold the dose, assess the apical rate for a full minute, and notify the provider for potassium replacement. Option 1 is unsafe because the therapeutic level does not account for the potassium. Option 3 is appropriate teaching later but does not address the immediate risk. Option 4 would worsen the hypokalemia.

Question 2

Select all that apply. A nurse assesses a client receiving digoxin. Which findings suggest digoxin toxicity?

1. Anorexia, nausea, and vomiting
2. Reports of yellow-green halos around lights
3. Apical pulse of 52 beats per minute
4. Serum potassium of 5.8 mEq/L reported as a new finding in a client with renal impairment
5. Blood pressure of 148/86 mm Hg

Answer: Options 1, 2, 3, and 4.

Rationale: Gastrointestinal upset is often the earliest symptom, visual disturbance with yellow-green halos is classic, and bradycardia below 60 beats per minute is a hallmark cardiac effect. Hyperkalemia can accompany acute digoxin toxicity and, in a client with renal impairment who cannot clear the drug, is a meaningful warning. Option 5 is unrelated; digoxin toxicity is not characterized by hypertension.

Question 3

A client with a chronic obstructive pulmonary disease exacerbation has these arterial blood gas results: pH 7.28, PaCO2 62 mm Hg, HCO3 26 mEq/L, PaO2 58 mm Hg. How should the nurse interpret these results?

1. Uncompensated metabolic acidosis
2. Uncompensated respiratory acidosis with hypoxemia
3. Fully compensated respiratory alkalosis
4. Partially compensated metabolic alkalosis

Answer: Option 2. Uncompensated respiratory acidosis with hypoxemia.

Rationale: The pH is below 7.35, indicating acidemia. The PaCO2 is elevated above 45 mm Hg, which is the respiratory component and moves in the direction that explains the acidemia. The bicarbonate is still within the normal range of 22 to 26 mEq/L, so metabolic compensation has not yet occurred, making this uncompensated. The PaO2 of 58 mm Hg is well below 80 mm Hg and represents hypoxemia. Options 1, 3, and 4 misidentify the primary disturbance.

Question 4

Four hours after a femoral cardiac catheterization, a client reports new dull back and flank pain. Vital signs are blood pressure 88/54 mm Hg, heart rate 118 beats per minute, and respirations 24 breaths per minute. The groin dressing is dry and intact. What should the nurse do first?

1. Reposition the client and administer the ordered analgesic.
2. Apply additional pressure to the groin site and recheck in 15 minutes.
3. Notify the provider immediately and prepare for evaluation of retroperitoneal hemorrhage.
4. Ambulate the client to relieve the muscular back discomfort.

Answer: Option 3. Notify the provider immediately and prepare for evaluation of retroperitoneal hemorrhage.

Rationale: A dry groin dressing does not exclude bleeding, because blood from the femoral puncture can track into the retroperitoneal space. New back or flank pain with tachycardia and hypotension after femoral access is the classic presentation and requires urgent evaluation, typically with imaging and serial hemoglobin. Options 1 and 4 delay recognition of hemorrhage and mobilization is contraindicated. Option 2 does not address bleeding that is not at the surface and wastes critical time.

Question 5

Select all that apply. A client receiving chemotherapy has a platelet count of 18,000/mm3. Which interventions should the nurse include in the plan of care?

1. Provide an electric razor rather than a safety razor.
2. Avoid rectal temperature measurement and rectal suppositories.
3. Apply pressure to venipuncture sites for an extended period.
4. Administer ibuprofen as needed for mild headache.
5. Instruct the client to use a soft-bristled toothbrush and avoid flossing that causes gum trauma.

Answer: Options 1, 2, 3, and 5.

Rationale: A platelet count of 18,000/mm3 carries a risk of spontaneous bleeding, so full bleeding precautions apply: no sharp razors, no rectal trauma, prolonged pressure after any puncture, and gentle oral care. Option 4 is contraindicated because nonsteroidal anti-inflammatory drugs and aspirin impair platelet function and compound the bleeding risk; acetaminophen is generally the preferred analgesic in this situation, though fever in a client on chemotherapy must be reported rather than simply treated.

Question 6

A client receiving chemotherapy has an absolute neutrophil count of 380/mm3 and an oral temperature of 38.1 degrees Celsius (100.6 degrees Fahrenheit). The client has no cough, no dysuria, and no visible drainage. Which conclusion by the nurse is correct?

1. The absence of localized signs indicates the fever is not infectious.
2. The fever is low grade and can be rechecked in four hours.
3. The client is severely neutropenic and this fever is a medical emergency requiring immediate reporting and prompt blood cultures and antibiotics.
4. The client should be encouraged to increase fluids and the finding documented as expected during chemotherapy.

Answer: Option 3. The client is severely neutropenic and this fever is a medical emergency requiring immediate reporting and prompt blood cultures and antibiotics.

Rationale: An absolute neutrophil count below 500/mm3 is severe neutropenia. Without neutrophils, the client cannot generate purulent drainage, infiltrates, or a robust white count, so fever may be the only sign of overwhelming infection. Neutropenic fever is treated as an emergency, with cultures obtained and broad-spectrum antibiotics started rapidly. Options 1, 2, and 4 all delay life-saving treatment by misreading the absence of localizing signs as reassurance.

Question 7

On day 6 of unfractionated heparin therapy, a client's platelet count has fallen from 245,000/mm3 to 88,000/mm3, and the client now has a swollen, painful right calf. Which action is most appropriate?

1. Continue the heparin and add aspirin for the new clot.
2. Anticipate stopping all heparin products and notify the provider of suspected heparin-induced thrombocytopenia.
3. Transfuse platelets to correct the thrombocytopenia before any further anticoagulation.
4. Substitute enoxaparin because low molecular weight heparin does not cause this reaction.

Answer: Option 2. Anticipate stopping all heparin products and notify the provider of suspected heparin-induced thrombocytopenia.

Rationale: A substantial platelet drop after roughly five to ten days of heparin exposure, especially when accompanied by new thrombosis rather than bleeding, is the pattern of heparin-induced thrombocytopenia. It is an immune-mediated, prothrombotic reaction. All heparin exposure must stop, including flushes and coated catheters, and a non-heparin anticoagulant is substituted. Option 4 is wrong because low molecular weight heparins cross-react. Option 3 is generally avoided because platelet transfusion may fuel thrombosis. Option 1 continues the offending drug.

Question 8

Which client should the nurse on a medical-surgical unit assess first?

1. A client two days after abdominal surgery with a temperature of 37.9 degrees Celsius (100.2 degrees Fahrenheit) and diminished breath sounds at both bases.
2. A client with chronic kidney disease whose serum potassium is 5.9 mEq/L and who reports new muscle weakness.
3. A client with cirrhosis whose serum albumin is 2.6 g/dL and who has 2+ pitting ankle edema.
4. A client with type 2 diabetes whose fasting glucose is 168 mg/dL.

Answer: Option 2. The client with chronic kidney disease, potassium 5.9 mEq/L, and new muscle weakness.

Rationale: Hyperkalemia with new neuromuscular symptoms threatens lethal dysrhythmia and takes precedence over all the other findings. Option 1 most likely represents atelectasis, which is expected and important but not immediately life threatening. Options 3 and 4 are chronic, expected findings consistent with each client's diagnosis. The prioritization rule is unstable over stable and unexpected over expected, with cardiac risk at the top.

Question 9

Eight hours after a total thyroidectomy, a client reports numbness and tingling around the mouth and in the fingertips. Which action should the nurse take first?

1. Assess for Chvostek and Trousseau signs and notify the provider.
2. Reassure the client that this is a normal effect of anesthesia.
3. Increase the intravenous fluid rate.
4. Apply warm compresses to the hands.

Answer: Option 1. Assess for Chvostek and Trousseau signs and notify the provider.

Rationale: Perioral and digital paresthesias after thyroidectomy suggest hypocalcemia from inadvertent parathyroid gland injury or removal. Chvostek and Trousseau signs support the finding, and untreated hypocalcemia can progress to tetany and laryngospasm. Intravenous calcium gluconate should be readily available. Option 2 dismisses a dangerous finding. Options 3 and 4 do not treat the underlying problem or alert the provider.

Question 10

A client with type 2 diabetes who takes metformin is scheduled for a computed tomography scan with iodinated contrast. The serum creatinine is 1.9 mg/dL. Which nursing action is most important?

1. Verify the plan for withholding metformin around the time of contrast administration and confirm hydration orders.
2. Hold the client's morning insulin and check a fingerstick glucose.
3. Ask the client whether shellfish causes a rash, and cancel the study if so.
4. Administer the metformin with a small sip of water to maintain glycemic control.

Answer: Option 1. Verify the plan for withholding metformin around the time of contrast administration and confirm hydration orders.

Rationale: Impaired renal function raises the risk of contrast-associated kidney injury, and reduced metformin clearance in that setting raises the risk of lactic acidosis. Standard practice is to withhold metformin at the time of contrast and for approximately 48 hours afterward in at-risk clients, restarting only after renal function is reassessed, along with adequate hydration. Option 3 reflects an outdated belief; shellfish allergy does not predict contrast reaction, whereas a prior reaction to contrast itself does. Option 4 is unsafe, and option 2 does not address the primary risk.

Question 11

A nurse observes continuous vigorous bubbling in the water seal chamber of a client's closed chest drainage system. What is the nurse's priority action?

1. Document the finding as an expected sign of lung re-expansion.
2. Clamp the chest tube near the insertion site for 30 minutes and reassess.
3. Assess the system and the insertion site for an air leak, tightening connections and checking the dressing, then notify the provider if it persists.
4. Strip the tubing to clear any obstruction.

Answer: Option 3. Assess the system and the insertion site for an air leak, tightening connections and checking the dressing, then notify the provider if it persists.

Rationale: Continuous bubbling in the water seal chamber indicates air entering the system, either from the client or through a loose connection or dislodged dressing. The nurse systematically checks the tubing, connections, and site. Intermittent bubbling with exhalation or coughing can be expected while a pneumothorax resolves, and gentle continuous bubbling belongs in the suction control chamber of a wet system, not the water seal. Option 1 misidentifies the finding. Option 2 risks tension pneumothorax, since routine clamping is contraindicated. Option 4 causes dangerously high negative pressure and is not routine practice.

Question 12

Select all that apply. Fifteen minutes into a transfusion of packed red blood cells, a client reports low back pain and chills, and the temperature has risen 1.2 degrees Celsius. Which actions should the nurse take?

1. Stop the transfusion immediately.
2. Keep the intravenous line open with normal saline using new tubing.
3. Slow the transfusion rate and continue to observe.
4. Notify the provider and the blood bank.
5. Obtain vital signs and assess the urine for a red or dark color.

Answer: Options 1, 2, 4, and 5.

Rationale: Fever, chills, and low back pain early in a transfusion suggest an acute hemolytic reaction from ABO incompatibility, which is life threatening. The transfusion is stopped at once, and the line is maintained with normal saline through new tubing so that no further blood is infused. The provider and blood bank are notified, the product and tubing are returned per policy, and hemoglobinuria is assessed. Option 3 is unsafe because any continued infusion of incompatible blood worsens hemolysis.

Question 13

Thirty minutes after a thoracentesis, a client becomes acutely short of breath with sharp right-sided chest pain. Breath sounds are markedly diminished on the right, the heart rate is 124 beats per minute, and oxygen saturation has fallen from 96 percent to 87 percent. What complication should the nurse suspect and what is the priority action?

1. Re-expansion pulmonary edema; administer the ordered diuretic.
2. Pneumothorax; administer oxygen, place the client in high Fowler position, notify the provider, and prepare for a chest radiograph.
3. Anxiety reaction; coach the client in pursed-lip breathing.
4. Pulmonary embolism; ambulate the client to improve circulation.

Answer: Option 2. Pneumothorax; administer oxygen, place the client in high Fowler position, notify the provider, and prepare for a chest radiograph.

Rationale: Pneumothorax is the most common serious complication of thoracentesis, presenting with sudden dyspnea, pleuritic pain, diminished or absent breath sounds on the affected side, tachycardia, and desaturation. Oxygen and an upright position support ventilation while the provider is notified and imaging is obtained, with chest tube insertion anticipated. Option 1 describes a different complication that follows removal of very large volumes and presents with bilateral crackles. Option 3 dismisses objective hypoxemia. Option 4 misattributes the findings and ambulation would be unsafe.

Question 14

A client with cirrhosis and hepatic encephalopathy is receiving lactulose. Which finding best indicates a therapeutic response?

1. The client has two to three soft stools daily and is oriented to person, place, and time.
2. The client reports relief of abdominal bloating.
3. The serum albumin has risen from 2.4 to 2.6 g/dL.
4. The client has had no stool in 24 hours and reports less cramping.

Answer: Option 1. The client has two to three soft stools daily and is oriented to person, place, and time.

Rationale: Lactulose lowers serum ammonia by trapping it in the bowel and eliminating it in stool. The dose is titrated to produce roughly two to three soft stools per day, and improving mental status is the definitive measure of effectiveness. Option 4 indicates an inadequate dose. Option 2 is nonspecific. Option 3 reflects synthetic liver function and nutrition rather than the drug's action, and the change is minimal.

Question 15

A client with severe pre-eclampsia is receiving an intravenous magnesium sulfate infusion. The nurse finds the patellar deep tendon reflex absent, a respiratory rate of 10 breaths per minute, and urine output of 20 mL over the past hour. Which action should the nurse take first?

1. Increase the infusion rate to control the blood pressure.
2. Stop the magnesium sulfate infusion, notify the provider, and have calcium gluconate available.
3. Administer a bolus of intravenous fluid and recheck reflexes in one hour.
4. Document the findings as expected effects of therapy.

Answer: Option 2. Stop the magnesium sulfate infusion, notify the provider, and have calcium gluconate available.

Rationale: Loss of deep tendon reflexes is the earliest reliable warning of magnesium toxicity, followed by respiratory depression, and it is compounded here by oliguria, since magnesium is renally excreted. The infusion is stopped immediately, the provider is notified, and calcium gluconate is the antidote. Option 1 would worsen toxicity. Option 3 delays intervention in the face of respiratory depression. Option 4 misclassifies dangerous toxicity as an expected effect; mild reduction in reflexes may be monitored closely, but absent reflexes with bradypnea and oliguria is not.

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