NCLEX-RN
RN Reduction of Risk Potential in Nursing Questions
Question 1 of 5
The nurse is assessing a client with a stage 3 pressure ulcer. Which finding is consistent with this type of pressure ulcer?
Correct Answer: B
Rationale: Stage 3 pressure ulcers involve full-thickness skin loss with visible subcutaneous fat and possible undermining, but not muscle or bone exposure.
Question 2 of 5
A nurse is caring for a client, diagnosed with Parkinson's disease, who scored as a high-risk fall candidate on the St. Thomas Risk Assessment Tool in Falling Elderly Inpatients. Which nursing interventions should the nurse implement? Select all that apply.
Correct Answer: A,B,D
Rationale: For a high fall risk client with Parkinson's, a call-light (
A), low bed (
B), and bed alarm (
D) reduce fall risk. Beveled mats (
C) are less standard and may pose tripping hazards.
Question 3 of 5
The nurse is caring for a client who has a lithium level of 2.2 mEq/L. Based on this lab value, what would the nurse anticipate to do in order to care for this client? Select all that apply.
Correct Answer: A,B,E
Rationale: A lithium level of 2.2 mEq/L indicates toxicity, requiring IV fluids (
A), provider notification (
B), and monitoring for symptoms like confusion and slurred speech (E). Diet (
C) is unrelated, and further lithium (
D) is contraindicated.
Question 4 of 5
The nurse is caring for a client with dementia who has pulled out three peripheral IVs. Which intervention by the nurse is the best way to manage this client?
Correct Answer: C
Rationale: Wrapping the IV in gauze (
C) is a least-restrictive method to prevent removal while maintaining dignity. Restraints (
A) are a last resort, family presence (
B) is impractical, and threats (
D) are nontherapeutic.
Question 5 of 5
The nurse has received shift report on the assigned client. Which client would the nurse anticipate to be at highest risk for skin breakdown?
Correct Answer: D
Rationale: Severe weakness and neuropathy (
D) impair mobility and sensation, increasing pressure ulcer risk. Other clients have lower risk due to mobility or controlled conditions.