NCLEX-RN
Reduction of Risk Potential NCLEX RN Questions Questions
Extract:
Question 1 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 2 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 3 of 5
A client is scheduled for a CT of the brain with and without IV contrast dye to evaluate a possible hemorrhage. Which finding in the client's history should the nurse report immediately to the health care provider?
Correct Answer: A
Rationale: Shellfish allergy indicates a potential iodine allergy, which is critical for IV contrast safety, requiring immediate provider notification.
Question 4 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.
Question 5 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.