NCLEX Reduction of Risk Potential 2 — Questions and Answers
Question 1: A client's serum potassium level is 6.8 mEq/L. Which finding requires the nurse's immediate attention?
- Peaked T waves on the ECG (Correct answer)
- Increased urine output
- Hyperactive bowel sounds
- Warm, dry skin
Correct answer: Peaked T waves on the ECG
Peaked T waves indicate cardiac membrane instability from hyperkalemia and can progress to lethal dysrhythmias.
Question 2: Before a paracentesis, which nursing action reduces the client's risk of injury?
- Having the client empty the bladder (Correct answer)
- Placing the client supine and flat
- Withholding all oral fluids for 24 hours
- Administering a sedative routinely
Correct answer: Having the client empty the bladder
Emptying the bladder lowers the risk of accidental bladder puncture during needle insertion.
Question 3: A client is scheduled for an MRI. Which item must the nurse ensure is removed or addressed?
- Implanted cardiac pacemaker (Correct answer)
- Cotton hospital gown
- Plastic identification band
- Removable dentures
Correct answer: Implanted cardiac pacemaker
A pacemaker contains ferromagnetic components and electronics that the strong magnetic field can disrupt, posing serious harm.
Question 4: Which lab value should the nurse review before a client receives a contrast dye CT scan?
- Serum creatinine (Correct answer)
- Serum sodium
- White blood cell count
- Serum albumin
Correct answer: Serum creatinine
Contrast dye is nephrotoxic, so baseline renal function via creatinine must be assessed to reduce kidney injury risk.
Question 5: A client on warfarin has an INR of 5.2. Which action does the nurse anticipate?
- Holding the next warfarin dose (Correct answer)
- Administering an extra warfarin dose
- Encouraging vitamin K-rich foods only
- Increasing the warfarin dose
Correct answer: Holding the next warfarin dose
An INR of 5.2 is above therapeutic range and increases bleeding risk, so warfarin is held to reduce that risk.
Question 6: After a liver biopsy, in which position should the nurse place the client to reduce bleeding risk?
- Right side-lying with a pillow against the site (Correct answer)
- High Fowler's position
- Left side-lying
- Prone with arms overhead
Correct answer: Right side-lying with a pillow against the site
Lying on the right side applies pressure to the biopsy site and helps prevent hemorrhage.
Question 7: Which client statement before a colonoscopy indicates a need for further teaching?
- "I ate a steak dinner last night." (Correct answer)
- "I drank the bowel prep solution."
- "I stopped iron supplements last week."
- "I arranged for a ride home."
Correct answer: "I ate a steak dinner last night."
Eating solid food the night before prevents adequate bowel preparation and increases procedure risk and need to repeat.
NCLEX Reduction of Risk Potential 2
A client's serum potassium level is 6.8 mEq/L.
Which finding requires the nurse's immediate attention?