NCLEX-RN
RN Reduction of Risk Potential NCLEX Questions
Question 1 of 5
The nurse is caring for a client with a history of cirrhosis of the liver. Lab values reveal rising ammonia levels. Which of the following actions should the nurse anticipate performing? Select all that apply.
Correct Answer: B,D
Rationale: Rising ammonia in cirrhosis causes encephalopathy, so rest (
B) and monitoring mental status (
D) are needed. Straight razors (
A) increase bleeding risk, and potassium restriction (
C) is unrelated.
Question 2 of 5
An elderly man is admitted to the ED during the night shift. He reports slipping and hitting his forehead on the bathtub several hours earlier. The nurse is assessing the client's frontal lobe function. Which of the following questions/statements should the nurse ask the client?
Correct Answer: D
Rationale: The frontal lobe handles executive functions like calculation. Asking a math question (
D) assesses this.
Touch (
A) tests parietal, hearing (
B) tests temporal, and balance (
C) tests cerebellar function.
Question 3 of 5
The nurse is caring for a client who just had an arteriovenous (AV) fistula placed for dialysis. The nurse is providing home care instructions to the client. Which statement by the client indicates a need for further teaching by the nurse?
Correct Answer: D
Rationale: Tight sleeves can compress the AV fistula, impairing blood flow, indicating a need for further teaching. Other statements are correct.
Question 4 of 5
The nurse is performing an admission assessment on a client with thrombocytopenia. Which signs and symptoms and lab findings would the nurse expect to see in this client? Select all that apply.
Correct Answer: A,B
Rationale: Thrombocytopenia causes bleeding tendencies like epistaxis (
A) and petechiae (
B). Vomiting blood (
C) is less common, and hematocrit (
D) and platelets (E) are decreased, not elevated.
Question 5 of 5
The nurse is preparing to perform a focused abdominal assessment on a client. Which is the correct order of this assessment?
Correct Answer: A
Rationale: The correct order is inspection, auscultation, palpation, percussion to avoid altering bowel sounds with palpation or percussion before auscultation.