NCLEX Reduction of Risk Potential 3 — Questions and Answers
Question 1: A client receiving a blood transfusion develops fever, chills, and low back pain after 15 minutes. What is the nurse's priority action?
- Stop the transfusion immediately (Correct answer)
- Slow the infusion rate
- Administer acetaminophen
- Document and continue monitoring
Correct answer: Stop the transfusion immediately
These signs suggest an acute hemolytic reaction, and stopping the transfusion prevents further harm.
Question 2: Which value indicates the client on heparin therapy is at increased risk for bleeding?
- aPTT of 120 seconds (Correct answer)
- Platelet count of 250,000/mm3
- Hemoglobin of 14 g/dL
- INR of 1.0
Correct answer: aPTT of 120 seconds
An aPTT of 120 seconds exceeds the therapeutic range, indicating excessive anticoagulation and bleeding risk.
Question 3: Before administering digoxin, the nurse notes an apical pulse of 52 beats/min. What should the nurse do?
- Hold the dose and notify the provider (Correct answer)
- Give the dose as scheduled
- Give half the dose
- Recheck the pulse in 4 hours then give
Correct answer: Hold the dose and notify the provider
Digoxin is withheld when the apical pulse is below 60 beats/min to prevent further bradycardia.
Question 4: A client's pulse oximetry reads 86% on room air. Which action reduces the client's risk first?
- Apply supplemental oxygen (Correct answer)
- Call the rapid response team
- Reposition the probe
- Document the reading
Correct answer: Apply supplemental oxygen
An oxygen saturation of 86% indicates hypoxemia, and applying oxygen is the immediate intervention to reduce harm.
Question 5: Which finding in a postoperative client most strongly suggests internal hemorrhage?
- Falling blood pressure with rising pulse (Correct answer)
- Increased urine output
- Bradycardia with hypertension
- Warm, flushed extremities
Correct answer: Falling blood pressure with rising pulse
Hypotension with tachycardia reflects the body's compensatory response to blood loss.
Question 6: A client with a chest tube has continuous bubbling in the water-seal chamber. What does this indicate?
- An air leak in the system (Correct answer)
- Normal lung re-expansion
- Tube obstruction
- Complete lung healing
Correct answer: An air leak in the system
Continuous bubbling in the water-seal chamber signals an air leak that must be located and corrected.
Question 7: Which lab result should the nurse report before a client receives metformin and contrast dye?
- Elevated serum creatinine (Correct answer)
- Low serum potassium
- Elevated white blood cell count
- Low serum calcium
Correct answer: Elevated serum creatinine
Elevated creatinine with metformin and contrast increases the risk of lactic acidosis and acute kidney injury.
NCLEX Reduction of Risk Potential 3
A client receiving a blood transfusion develops fever, chills, and low back pain after 15 minutes.
What is the nurse's priority action?