WorksheetsReduction of Risk Potential-NCLEX-RN
Total questions: 25
Worksheet time: 13mins
A client receiving continuous cardiac monitoring has a potassium level of 6.1 mEq/L. Which assessment finding requires immediate intervention?
Muscle weakness
Peaked T waves
Nausea
Decreased bowel sounds
A postoperative client reports sudden shortness of breath and anxiety. Which additional finding is most concerning?
Oxygen saturation 94%
Blood pressure 148/86
Sharp chest pain with inspiration
Pain at the surgical site
The nurse is reviewing laboratory trends. Which finding represents the highest risk?
Hemoglobin decreasing from 13 to 11 g/dL
Sodium decreasing from 138 to 134 mEq/L
Potassium increasing from 4.8 to 5.6 mEq/L
BUN increasing from 18 to 22 mg/dL
A client receiving IV heparin has an aPTT of 98 seconds. What is the priority nursing action?
Administer vitamin K
Hold the infusion
Increase the infusion rate
Reassess in one hour
A client scheduled for a CT scan with contrast has a creatinine of 2.1 mg/dL. What is the nurse’s priority action?
Encourage oral fluids
Administer contrast as ordered
Notify the provider
Place the client NPO
Which assessment finding in a client with hypocalcemia requires immediate action?
Constipation
Bone pain
Tingling around the mouth
Muscle twitching in hands
The nurse is caring for a client with a newly inserted central venous catheter. Which finding is most concerning?
Mild tenderness at insertion site
Blood return present
Sudden dyspnea and chest pain
Transparent dressing in place
A client with COPD is receiving oxygen at 6 L/min via nasal cannula. Which finding requires intervention?
Oxygen saturation 92%
Respiratory rate 10/min
Warm, dry skin
Productive cough
Which lab value places a client at highest risk for bleeding?
INR 1.2
Platelets 175,000
aPTT 82 seconds
Hematocrit 41%
A client becomes restless and confused after surgery. Which complication should the nurse suspect first?
Infection
Hypoxia
Fluid overload
Hyperglycemia
Which finding in a postoperative client suggests early internal bleeding?
Blood pressure 88/52
Increased bowel sounds
Decreasing urine output
Elevated temperature
Which assessment finding in a client receiving warfarin requires immediate follow-up?
INR 1.9
Bruising on arms
Dark, tarry stools
Gum bleeding while brushing
Which client is at highest risk for contrast-induced nephropathy?
Young adult with asthma
Older adult with diabetes
Client with hypertension
Client with anemia
Which finding indicates increased intracranial pressure?
Tachycardia
Restlessness
Bradycardia
Hypotension
A client receiving magnesium sulfate has absent deep tendon reflexes. What is the priority action?
Increase the infusion
Administer calcium gluconate
Reassess in 30 minutes
Encourage fluids
Which laboratory value requires immediate intervention?
Sodium 133 mEq/L
Calcium 7.0 mg/dL
Glucose 160 mg/dL
Magnesium 1.7 mg/dL
Which postoperative finding requires immediate notification of the provider?
Incisional pain rated 6/10
Oxygen saturation 89%
Temperature 99.1°F
Minimal serous drainage
A client suddenly develops hypotension after central line removal. What complication is most likely?
Infection
Pneumothorax
Air embolism
Hemorrhage
Which assessment finding indicates early sepsis?
Hypotension
Bradycardia
Increased respiratory rate
Decreased temperature
Which finding places a client at highest risk for falls?
Blood glucose 140 mg/dL
Hemoglobin 11 g/dL
Orthostatic hypotension
Oxygen saturation 94%
A client reports numbness and tingling after thyroid surgery. What is the nurse’s priority concern?
Hypothyroidism
Hypocalcemia
Infection
Hematoma
Which finding suggests early respiratory failure?
Oxygen saturation 93%
Shallow respirations
Increasing restlessness
Productive cough
Which lab trend is most concerning?
Sodium 140 → 137
Hemoglobin 12 → 10
Potassium 4.2 → 5.4
BUN 15 → 18
Which assessment finding requires immediate action in a client with a chest tube?
Tidaling in water seal chamber
Continuous bubbling in suction chamber
Sudden absence of breath sounds
Drainage of 50 mL in 8 hours
Which situation best represents Reduction of Risk Potential?
Administering pain medication
Teaching about diet changes
Monitoring labs for trends
Providing emotional support
