NCLEX-RN Reduction of Risk Potential practice questions

Question 1

A 72-year-old client is admitted to the telemetry unit with a diagnosis of dehydration. The nurse obtains vital signs: blood pressure 100/58 mm Hg, heart rate 108 beats/min, respiratory rate 22 breaths/min, temperature 37.1°C (98.8°F), and oxygen saturation 96% on room air. Which vital sign finding is most concerning and requires immediate intervention?

1. A Heart rate 108 beats/min
2. B Respiratory rate 22 breaths/min
3. C Blood pressure 100/58 mm Hg
4. D Oxygen saturation 96% on room air

Question 2

A 48-year-old client undergoes an open colectomy for colon cancer. On postoperative day 3, the nurse assesses the client and finds a temperature of 38.9°C, heart rate 100 beats/min, blood pressure 100/60 mm Hg, and the surgical wound has purulent drainage with a foul odor. Which finding indicates the most likely complication?

1. A Serum lactate level of 0.8 mmol/L and normal coagulation studies.
2. B Abdominal girth increased by 2 cm from the previous day.
3. C Increased white blood cell count of 14,000/mm³ with left shift.
4. D Bowel sounds are hypoactive in all four quadrants.

Question 3

A 50-year-old client with a history of cirrhosis is admitted with acute gastrointestinal bleeding. The nurse assesses the client and notes the following: heart rate 118 beats/min, blood pressure 90/56 mm Hg, respiratory rate 24 breaths/min, and oxygen saturation 94% on room air. The client reports feeling lightheaded. Which nursing action should the nurse perform first?

1. A Obtain a STAT complete blood count and coagulation panel
2. B Notify the healthcare provider of the vital signs and symptoms
3. C Prepare the client for an urgent upper endoscopy
4. D Administer a bolus of 0.9% sodium chloride 500 mL intravenously

Question 4

A 55-year-old client with a history of peptic ulcer disease presents to the emergency department with sudden severe epigastric pain, board-like abdominal rigidity, and a heart rate of 110 beats/min. The nurse anticipates which diagnostic test to confirm the suspected complication?

1. A Upper gastrointestinal endoscopy with biopsy.
2. B Serum amylase and lipase levels.
3. C Abdominal ultrasound of the gallbladder.
4. D Upright chest radiograph for free air.

Question 5

A 72-year-old client in the medical-surgical unit has a chest tube connected to a water-seal drainage system. The nurse notes that the fluid in the water-seal chamber has stopped fluctuating and the client reports new-onset dyspnea with oxygen saturation of 89% on room air. Which action should the nurse take first?

1. A Notify the healthcare provider of the change in the client's condition
2. B Increase the supplemental oxygen to 4 L/min via nasal cannula
3. C Assess the chest tube insertion site and tubing for kinks or disconnection
4. D Milk the chest tube toward the drainage collection chamber to clear clots

Question 6

A 34-year-old female is admitted with acute pancreatitis. Her heart rate is 108/min, blood pressure 104/72 mm Hg, respiratory rate 20/min, and temperature 38.1°C. The nurse notes abdominal distension, absent bowel sounds, and a serum calcium level of 7.8 mg/dL. Which complication should the nurse monitor for most closely?

1. A Hypovolemic shock
2. B Pleural effusion
3. C Hyperglycemia
4. D Pancreatic pseudocyst

Question 7

A 55-year-old client with chronic kidney disease is scheduled for an arteriovenous fistula placement in the left forearm. The nurse is providing preoperative teaching. Which statement by the client indicates a need for further teaching?

1. A I will avoid having blood drawn from my left arm after the surgery
2. B I can expect to hear a buzzing feeling over the fistula site soon after surgery
3. C I will need to keep my left arm bent at the elbow for the first 24 hours
4. D I should report any numbness or tingling in my left hand to the nurse

Question 8

A 55-year-old client with chronic kidney disease stage 3 is admitted for elective hernia repair. Preoperative laboratory results show serum potassium 5.8 mEq/L, serum creatinine 2.4 mg/dL, blood urea nitrogen 42 mg/dL, and hemoglobin 10.2 g/dL. Which laboratory value is most concerning for the perioperative period?

1. A Blood urea nitrogen 42 mg/dL
2. B Serum creatinine 2.4 mg/dL
3. C Serum potassium 5.8 mEq/L
4. D Hemoglobin 10.2 g/dL

Question 9

A 62-year-old client with type 2 diabetes is 2 hours post-hip arthroplasty and reports feeling shaky and anxious. The nurse notes a heart rate of 98 beats per minute and a blood pressure of 118/76 mm Hg. The client's last insulin dose was 6 units of lispro given 3 hours ago with breakfast. Which action should the nurse take first?

1. A Recheck the client's blood pressure in 15 minutes
2. B Check the client's capillary blood glucose level now
3. C Give the client 4 ounces of orange juice by mouth
4. D Review the client's hemoglobin A1c result from admission

Question 10

A 30-year-old client admitted for observation after a motor vehicle collision has the following vital signs: heart rate 104/min, blood pressure 100/62 mm Hg, respiratory rate 22/min, oxygen saturation 97% on room air, and temperature 98.6°F (37.0°C). The client is alert and oriented, with no visible injuries. Which vital sign change should the nurse report to the provider as the earliest sign of potential hypovolemic shock?

1. A Blood pressure of 100/62 mm Hg, which is at the lower end of the normal range.
2. B Respiratory rate of 22/min, which is above the normal range of 12-20/min.
3. C Heart rate of 104/min, which is above the normal resting range of 60-100/min.
4. D Temperature of 98.6°F (37.0°C), which is within the normal range.