NCLEX Reduction of Risk Potential 3

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?

Accepted Answer

Stop the transfusion immediately

Answer

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?

Accepted Answer

aPTT of 120 seconds

Answer

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?

Accepted Answer

Hold the dose and notify the provider

Answer

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?

Accepted Answer

Apply supplemental oxygen

Answer

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?

Accepted Answer

Falling blood pressure with rising pulse

Answer

Hypotension with tachycardia reflects the body's compensatory response to blood loss.

NCLEX Practice Test