NCLEX-RN
Reduction of Risk Potential NCLEX RN Questions Questions
Question 1 of 5
The nurse is preparing to remove a peripheral IV from a client. Which nursing action is the priority with this procedure?
Correct Answer: E
Rationale: Holding pressure until hemostasis (E) is the priority to prevent bleeding, especially in clients with anticoagulation or clotting issues.
Question 2 of 5
The nurse is caring for a client who just arrived in the PACU following a colonoscopy with polyp removal. The client's level of sedation is assessed using the Ramsay Sedation Scale (RSS). The client responds quickly, but only to commands. What Ramsay score would the nurse chart for this client?
Correct Answer: C
Rationale: RSS 3 indicates a client who responds quickly to commands only, consistent with moderate sedation post-procedure.
Question 3 of 5
A nurse is monitoring a client's intracranial pressure (ICP) after a motor vehicle accident. Upon checking the ICP, the nurse knows to contact the physician. What reading would warrant this action?
Correct Answer: D
Rationale: Normal ICP is 5-15 mm Hg. A reading of 22 mm Hg (
D) indicates elevated ICP, requiring immediate physician notification. Lower readings (A, B,
C) are within or near normal.
Question 4 of 5
The nurse is caring for a client who was admitted with an upper respiratory infection. The client's temperature is 102.4°F, and he is confused. In the last 2 hours, systolic blood pressure has dropped from 138 to 90. The nurse should perform which intervention? Select all that apply.
Correct Answer: A,C,D,E
Rationale: Fever, confusion, and hypotension suggest sepsis, requiring blood cultures (
A), oxygen (
C), antipyretics (
D), and rest (E). NPO (
B) is unnecessary, and warming blankets (F) may worsen fever.
Question 5 of 5
The nurse is assessing a client with a diagnosis of chronic obstructive pulmonary disease (COPD) exacerbation. Which finding would be expected for this client?
Correct Answer: C
Rationale: COPD exacerbation causes airway obstruction, leading to hypoxemia (low oxygen) and hypercarbia (high CO2) due to impaired gas exchange.