NCLEX Practice Test for Reduction of Risk Potential 2023 (40 Questions with Explained Answers)

welcome to the 2023 NCLEX reduction of risk potential practice test this test will have 40 questions with explained answers that will help you prepare for the test be sure to resuscitate the like button by turning it white question one a 20 year old patient with Down Syndrome is unable to perform oral hygiene and has no family with him which of the following is the responsibility of the UAP a use a soft tooth that to clean the teeth and tongue after each meal B use a soft toothbrush to clean the gums teeth and tongue after each meal C perform oral suction after rinsing the mouth with water after each meal D have the patient rinse with water after each meal the correct answer is B use a soft toothbrush to clean the gums teeth and tongue after each meal when a patient cannot perform proper mouth hygiene the UAP or nurse should clean the gums teeth and tongue after each meal this prevents the patient from having a mouth infection mouthwash can irritate the oral mucosa water is not enough to clean the oral mucosa a soft tooth head is not strong enough to properly clean the patient's mouth question two a seven-year-old patient presents to the Ed after falling from his tree house x-rays show that the patient sustained a green stick fracture which of the following correctly identifies a green stick fracture a it happens at the epiphyseal plate that has not yet stopped growing B happens with great trauma and force to the end of the bone C is also known as a hairline fracture D are usually seen in the older adults the correct answer is a it happens at the epiphyseal plate that has not yet stopped growing green stick fractures are seen in children who are not finished growing these children have epiphyseal plates that have not closed yet because they are still growing question three a patient presents to the Ed complaining of a severe stomach ache to her right lower abdomen the patient is diagnosed with appendicitis after a CT scan the patient is later admitted to the medical surgical unit which of the following if stated by the patient would indicate a medical emergency a my stomach is hurting so bad I just cannot take this B finally this pain has subsided maybe it was bad gas is the doctor sure I have appendicitis C when am I having this surgery I am so thirsty I feel so parched d I hope I get to go home tomorrow surely I can take pain meds and feel better after my surgery the correct answer is be finally this pain has subsided maybe it was bad gas is the doctor sure I have appendicitis this patient had intense pain and was diagnosed with appendicitis if the pain is suddenly gone this indicates that the patient's appendix has ruptured and the patient needs emergency surgery left untreated this will result in the patient's death quickly question four a patient who has recently undergone a thyroidectomy has a positive trustex and positive trussos sign these indicate all of the following except a hypocalcemia b damaged parathyroid gland C hypercalcemia D hypomagnesemia the correct answer is C hypercalcemia a positive chvostex sign and a positive trousseau sign indicates hypocalcemia hypomagnesemia and a damaged parathyroid gland patients with a positive chvostex sign and a positive trousseau sign would not have hypercalcemia question five a patient presents to an Urgent Care stating that he noticed that his great toe is swollen red and tender he states that it is so swollen that he has missed work for two days the patient states that his diet consists of red meats and beer at least five days per week which of the following would the nurse most likely expect the patient to be diagnosed with a cellulitis of the great toe B gout C rheumatoid arthritis D osteoarthritis the correct answer is B gout a patient who has a diet high in red meat and alcohol is at a high risk for gout due to uric acid this patient has the classic signs of gout given that the pain and inflammation started in his great toe question six the nurse is assessing a patient with a new ileostomy the nurse notices that the ostomy is purple which of the following is most likely the issue with the new ileostomy a nothing this is normal since it is outside of the abdomen B the bowel has become ischemic see the stoma has become dry D the stoma the correct answer is B the bowel has become ischemic a stoma for any type of ostomy should be pink slash red and moist if the stoma is purple it has become ischemic and is a medical emergency because the patient can lose that part of their bowel question seven the nurse is caring for a patient in an external fixation device on an orthopedic unit what is the most important nursing intervention for this patient a offer high protein meals B encourage the patient to ambulate often to prevent contractures C assess for excess redness around insertion sites D ensure the patient is in a left lateral position while in bed the correct answer is C assess for excess redness around insertion sites when a patient is in an external fixation device the insertion sites should be assessed often these sites can become infected easily excessive redness pus and or exudate can indicate infection at the insertion sites the patients are usually on bed rest and are in a supine position question eight a nurse is providing an enema to a 75 year old female patient the following are high risks when administering an enema to an older adult except a hypercalce semia b hyperphosphatemia c sepsis D death the correct answer is a hypercalcemia as adults age the bowel becomes thinner the older adult is at a much higher risk of bowel perforation and sepsis due to bowel perforation than a younger adult the older adult patient is at a high risk for hyperphosphatemia because enemas such as a Fleet enema have an active ingredient of sodium phosphate older adults are also at a higher risk of hypocalcemia with these types of enemas too the above conditions put the older adult at a high risk of kidney failure and even death question 9 an ed nurse is educating a 17 year old patient and her parents with a newly placed plaster cast to her left arm after sustaining a wrist fracture which of the following is the most important thing to educate the patient and parents on a reporting blue fingers immediately B keeping the arm in the sling provided C do not stick anything in the cast to scratch the skin D reporting fever immediately the correct answer is a reporting blue fingers immediately blue slash purple slash gray fingers May indicate lack of oxygen if the fingers become ischemic it becomes a medical emergency so that the patient does not lose their fingers question 10. the nurse is caring for an 87 year old new home health patient who has had an extended stay in the hospital after a fall that led to a broken hip that required a hip replacement followed by hospital-acquired pneumonia which of the following is most important for the nurse to educate the family on a ensure the patient's oxygen cord reaches to her bathroom B remove all throw rugs in the home C ensure the patient performs her breathing exercises daily D ensure the patient takes all medications as prescribed the correct answer is B remove all throw rugs in the home the number one thing to remember is the patient's safety while all the other options are good to remember for this patient we should focus on why she was in the hospital to begin with it was Falls removing the throw rugs in the home is the best intervention to prevent Falls for this patient question 11 the nurse is caring for a patient who recently suffered a stroke The Physician orders for the patient to be Advanced to a clear liquid diet from NPO before allowing the patient to drink which of the following is most important for the nurse to confirm a the patient's favorite drink B if the the patient needs thickened liquids C if the patient is urinating D if the patient has vomited in 24 hours the correct answer is B if the patient needs thickened liquids before increasing their diet patients with dysphagia should have a thorough swallow examination especially if it is caused by a stroke or brain hemorrhage additional treatments in therapy would be necessary if clients were observed to exhibit aspiration or choking Tendencies during swallowing a speech pathologist can recommend thickened liquids if needed in this case a patient with a history of a stroke is cleared to drink this patient should be cleared by a speech pathologist before receiving fluids by mouth the nurse should check the patient's chart to see if the patient has an order for thickened liquids question 12 a nurse working in the Intensive Care Unit has a patient that is experiencing a sudden upper gastrointestinal bleed what is the most important intervention a place the patient in a Trendelenburg position B place the patient in a Supine position C put the patient in Reverse Trendelenburg D put the patient in a Sims position the correct answer is a place the patient in a Trendelenburg position using the Trendelenburg position for patients with a high risk of hypertension like with a large GI bleed can be helpful in reducing the risk of hypertension in order to increase surgical exposure of the pelvic organs the surgeon Friedrich trendelenberg invented the head down posture often known as the Trendelenburg position the Trendelenburg position then became a frequently used technique in treating patients with shock and hypertension the Trendelenburg posture has an increased cardiac output as its main consequence while this is not a long-term therapy initially placing the patient in a Trendelenburg position can help prevent hypertension question 13 the nurse is caring for a diabetic patient who the nurse finds sweating and only able to mumble words what is the first intervention for the nurse to take a give glucagon B check Epoch glucose reading C ask the patient when the last time they ate D give four units of insulin stat the correct answer is B check a pot glucose reading the first intervention should be to assess the glucose if the nurse learns that it is in fact hypoglycemia the patient should be treated promptly if a patient is only able to mumble they are likely not able to answer any questions from the nurse glucagon is given to patients who are unconscious insulin should never be given to a hypoglycemic patient question 14 a nurse working on a labor and delivery unit suspects that her patient is having a seizure what is the most important intervention for the nurse to provide a administer oxygen to the patient B place the patient patient in a side lying position C insert an intravenous IV line D call for immediate assistance from the healthcare team the correct answer is D call for immediate assistance from the health care team the most important intervention for the nurse to provide when suspecting that a patient is having a seizure on a labor and delivery unit is to call for immediate assistance from the health care team seizures can be a medical emergency and it is crucial to ensure prompt and appropriate management calling for assistance ensures that additional Health Care Professionals such as a physician or advanced practice provider can evaluate and provide the necessary care to the patient while other interventions such as administering oxygen placing the patient in a sideline position to prevent aspiration or inserting an IV line may be appropriate and important in certain circumstances calling for immediate assistance takes priority to ensure the patient's safety and well-being question 15 a patient with severe migraines is ordered to have an MRI performed which of the following would be a contraindication for an MRI a the patient has a belly button piercing B the patient has a pacemaker C the patient has a decubitus on their sacrum D the patient has acrylic nails the correct answer is B the patient has a pacemaker a patient with a pacemaker should never be taken to an MRI machine the belly button ring can be removed a decubitus or acrylic does not keep a patient from getting an MRI question 16 a patient with a recent pneumothorax is ordered to have his chest tube removed the physician is at the bedside to pull the chest tube the nurse instructs the patient to Bear down and hold her breath what is the reason for this a to help the patient stay calm B to allow the lungs to inflate with air as the tube is removed C to prevent a fat embolism D to avoid sucking air into the lung as the tube is removed the correct answer is D to avoid sucking air into the lung as the tube is removed the point of the patient bearing down or performing the valsalva maneuver is to avoid sucking air into the lung as the tube is removed this technique places the patient at a lower risk for a recurrent pneumothorax question 17 a nurse caring for a patient with diverticulitis suspects that the patient has a bowel blockage which of the following signs would cause the nurse to think that the patient has a bowel blockage a the patient is having diarrhea but still has a bloated abdomen B the patient has high pitched bowel sounds at four per minute C the patient has not had a bowel movement in three days D the patient has vowel sounds in all quadrants that are low pitched the correct answer is B the patient has high pitched bowel sounds at 4 minute high-pitched bowel sounds indicate blockage bowel sounds should be heard at a minimum of 5 to 30 per minute 5 to 30 bowel sounds per minute is considered normoactive this patient exhibits symptoms of a bowel blockage question 18 a patient who broke her arm yesterday presents back to the Ed today with uncontrolled pain with opioid analgesics and is complaining of tingling in her fingertips which of the following is the patient likely experiencing a compartment syndrome B opioid dependence C chronic pain D Phantom Pain the correct answer is a compartment syndrome a patient with uncontrolled pain after a break in the bone is likely experiencing compartment syndrome this is considered a medical emergency because the patient is at risk for losing their arm question 19. a charge nurse is observing a new nurse who is caring for a patient after a liver biopsy which of the following if done by the new nurse would cause correction by the charge nurse a the nurse places the patient in a spine positioning for two hours post-biopsy B the nurse takes the patient ice chips post-biopsy C the nurse places the patient on her left side for four hours post-biopsy D the nurse educates the patient to leave the pressure dressing on the site of the biopsy the correct answer is a the nurse places the patient in a spine positioning for two hours post-biopsy a patient post-liver biopsy should be placed on their left side for four hours post-biopsy the patient should never be placed in the Supine position during the recovery period question 20 a medical surgical nurse is caring for a patient with a newly placed Salem sump that the doctor has ordered to be put on low intermittent suction lis what is the most accurate intervention to ensure that the Salem sump is in the stomach a instill a 10 mL air bolus while listening to the stomach with your stethoscope B obtaining an abdominal x-ray C pH tests D assessing the patient for respiratory distress the correct answer is B obtaining an abdominal x-ray obtaining an abdominal x-ray is the most accurate way to determine if a feed tube is in the stomach even if a patient is not in respiratory distress the tube may still not be in the stomach question 21 a patient with a chest tube accidentally pulls out the chest tube this can be an emergency what is the first intervention for the nurse to perform a place a finger with a sterile glove into the chest wall at the chest tube site B place an occlusive dressing on the insertion site and tape on three sides C put a wet occlusive dressing on the insertion site and tape on four sides D place the chest tube back into the insertion side and contact the physician immediately the correct answer is B place an occlusive dressing on the insertion site and tape on three sides if a patient's chest tube falls out or is pulled out the nurse should Place petroleum gauze in a sterile dry dressing over the site and tape it on three sides The Physician should be notified immediately the nurse's priority is to assess for respiratory distress question 22. a five-year-old who is post-op day one from a tonsillectomy and adenoidectomy is lying comfortably in his room the mom tells the nurse his breath smells so bad it smells like Rotting Flesh what is the best response by the nurse a I will let the doctor know immediately B this is normal following the procedure that your child had done see I will take a swab of his throat and send it to the lab D when was the last time he drank milk the correct answer is B this is normal following the procedure that your child had done it is normal for a patient who has undergone a tonsillectomy and adenoidectomy to have very bad smelling breath after surgery the smell can last up to two weeks and is due to scabbing of the sites where the tonsils and adenoids were excised by the surgeon question 23 a nurse is instructing a male patient on how to perform a clean catch urine specimen what is the proper way for a male patient to perform a clean catch specimen a open the sterile cup void into the toilet void into the cup close the lid and wipe the cup off with an alcohol wipe B use an antiseptic wipe to clean the meatus in a circular motion urinate into the sterile cup and close the lid C use an alcohol wipe to clean the meatus urinate into the sterile cup and close the lid D use an antiseptic wipe to clean the meatus in a circular motion open the sterile specimen cup void a little into the toilet void into the cup and close the lid the correct answer is D use an antiseptic wipe to clean the meatus in a circular motion open the sterile specimen cup void a little into the toilet void into the cup and close the lid in order for a male to perform a clean catch urine specimen properly he should use an antiseptic wipe to clean the meatus in a circular motion open the sterile specimen cup void a little into the toilet void into the cup and close the lid the female should perform the same steps except the female will use two antiseptic wipes to ensure that the inner labia is cleaned as well to prevent bacteria from entering into the urine specimen question 24 a nurse is working on an oncology unit with a patient with prostate cancer which of the following lab results will the nurse follow for this patient a ckmb b BMP C PSA D CMP the correct answer is C PSA the blood test to test for prostate cancer is PSA a high PSA May indicate a diagnosis of prostate cancer question 25 a home health nurse is educating a patient on wound healing which of the following is not a factor for quick wound healing a low carb diet B high protein diet corticosteroids D smoking cessation the correct answer is corticosteroids corticosteroids can diminish the patient's immune system and cause prolonged healing time a patient should follow a low carb high protein diet and stop smoking in order to promote proper wound healing question 26 the nurse is educating a patient on his risks for k-aide coronary artery disease which of the following is considered a non-modifiable risk factor for this patient a sedentary lifestyle B high sodium diet C smoking for 35 years D family history of CAD the correct answer is D family history of CAD a modifiable risk factor is something that can be modified by the patient a family history of CAD is out of the control of the patient all other options may be changed by the patient question 27 the nurse is monitoring a 25 year old for increased intracranial pressure after a motorcycle accident in which the patient was not wearing a helmet which of the following should be reported to the MD immediately a coughing B inability to say a forward phrase C the patient says I see two of everything D excessive laughing the correct answer is C the patient says I see two of everything it is not uncommon for a patient with increased ICP to experience diplopia double vision the child stating that he is seeing two of everything would indicate that he is experiencing double vision and the MD needs to be notified promptly question 28. the nurse is assisting a physician at the patient's bedside with inserting a chest tube what is the most important intervention by the nurse a keep a sterile field B make sure the patient is comfortable C make sure the patient is still D have all supplies ready when the physician arrives the correct answer is a keep a sterile field the chest tube is put in Via a surgical technique at the patient's bedside this means that it must be a sterile procedure the nurse's concern should be maintaining a sterile field while ensuring the patient is comfortable and still is correct this patient is at a very high risk for infection so the sterile field should be kept typically a second nurse would be ensuring that the patient is comfortable and still question 29 a patient is admitted to the ICU after an MVA the patient has an EVD placed the nurse knows that this device measures what a ICP intracranial pressure B CVP central venous pressure C ibp intra-abdominal blood pressure D Pap pulmonary artery pressure the correct answer is a ICP intracranial pressure devices called external ventricular drains evds are used to monitor intracranial pressure and offer a different route for cerebral spinal fluid CSF to exit the ventricles ICP the main justification for using evds is to treat high ICP following traumatic brain injury or due to other causes of hydrocephalus ibp is not a proper medical term question 30. a nurse is ordered to perform a true so test on a patient which of the following is the correct way for the nurse to assess this patient a run a cotton ball along the patient's cheek B place a blood pressure cuff on the patient's arm and Pump It Up 20 mm HG above the patient's normal systolic blood pressure C prick the patient's great Toe with a blunt sharp object D have the patient stand on one leg with their eyes closed the correct answer is B place a blood pressure cuff on the patient's arm and Pump It Up 20 mm HD above the patient's normal systolic blood pressure to perform a true so test the nurse should place a blood pressure cuff on the arm and pump it up to 20 mm-hg above the patient's normal blood pressure if the patient exhibits flexion of the wrist thumb and mCP joints and hyperextension of the IP joints this is considered a positive trousseau's sign and indicates hypocalcemia question 31 the nurse is providing education to a patient with newly diagnosed Diabetes Type 2. which of the following statements by the patient will need correction by the nurse a I will only have my podiatrist cut my toenails B I need to always wear socks to keep my feet dry see I need to soak my dry feet each night and rub them down with lotion D I should check my feet with a mirror each day the correct answer is C I need to soak my dry feet each night and rub them down with lotion a patient with diabetes does not need to soak their feet or add excessive amounts of lotion between their toes as this promotes a warm and wet bed for bacteria to grow patients with diabetes should have only their podiatrist cut their toenails should always wear socks to keep their feet dry and check their feet for sores with a mirror every day question 32 a nurse is observing a new UAP take vital signs on a patient with an AV fistula to her right arm which of the following if performed by the UAP would the nurse need to correct a the UAP places the blood pressure cuff on the right arm B the UAP takes an axillary temperature under the patient's right arm C the UAP places the blood pressure cuff on the left arm D the UAP takes an axillary temperature under the patient's left arm the correct answer is a the UAP places the blood pressure cuff on the right arm a blood pressure or a venipuncture should never be performed on an arm with an AV fistula doing so may lead to infection or may clot the AV fistula question 33 a quadriplegic patient is on a medical surgical unit being treated for sepsis from a decubitus ulcer which of the following is least likely to be included in the plan of care a risk for secondary infection B risk for shock C risk for deficient fluid volume D risk for Falls the correct answer is D risk for Falls this patient is a quadriplegic and cannot walk therefore the risk of Falls is very minimal risk for infection deficient fluid volumes and shock are most likely going to need to be on the care plan for this patient with sepsis question 34 a nurse is educating a patient about taking Warfarin a new medication for the patient which of the following statements by the patient would indicate that the patient understands the education provided by the nurse a I will take an extra Warfare and if my INR is under 2.0 B I will hold my Warfare in for a day if my INR is above three C I will report my Warfare and level to my doctor if my INR is under 2.0 or above 3.0 D I will report my Warfare and level to my doctor if my INR is 1.0 or above 4.0 the correct answer is C I will report my Warfare and level to my doctor if my INR is under 2.0 or above 3.0 a therapeutic INR range is 2.0 to 3.0 when the INR is outside of this range the patient should contact The Physician for orders if the INR is under two The Physician May recommend a higher dose of Warfarin if the INR is above three The Physician May recommend holding the next day's dose a patient taking Warfarin is oftentimes prescribed a monitor so that they can check their INR at home just like a glucose monitor this cuts down on office visits for these patients question 35 a patient presents to the Ed with symptoms of hypercalcemia the nurse knows that all of the following are symptoms of hypocalcemia except a profound weakness B confusion C concave abdomen D prolonged PR interval on EKG the correct answer is C concave abdomen a patient with hypercalcemia will have a distended abdomen profound weakness confusion and a prolonged PR interval on an EKG are all symptoms of hypercalcemia question 36 a nurse is observing a new nurse placing an NG tube which of the following if performed by the new nurse would warrant correction by the nurse a the new grad nurse places the patient in a high Fowler's position B the new grad nurse tells the patient to swallow as he is placing the NG tube C the new grad nurse measures from the nose to the earlobe to the xiphoid process D the new grad nurse continues to advance the NG tube as the patient coughs the correct answer is D the new grad nurse continues to advance the NG tube as the patient coughs if a patient coughs while an NG tube is being placed it is likely in the lung not the stomach the nurse should withdraw the NG tube and try again the nurse should have the patient perform a chin tuck while inserting the NG tube to decrease the risk of the NG tube entering the lungs question 37 a patient who is post-op arthritis to the left groin has asymmetrical pedal pulses the patient's right petal pulse is greater than her right what is the nurse's initial intervention a report this immediately to The Physician B get a pulse Doppler to assess pulses C lay the patient on her right side D place the patient in a Trendelenburg position the correct answer is a report this immediately to the physician after a patient undergoes an arthroscopy petal pulses should still be equal asymmetrical pedal pulses can indicate an issue with circulation and should be reported immediately to the physician question 38 a patient presents to the Ed with confusion and combativeness it is determined that the patient has a UTI which of the following patients is most likely to represent this patient's symptoms a a 35 year old pregnant woman who is 39 weeks six days pregnant b a 45 year old male with a fever c a 75 year old female who is incontinent d a five-year-old child who is developmentally delayed the correct answer is c a 75 year old female who is incontinent older adults who have a UTI are usually confused and can become combative when an older adult patient who is typically cognitively intact becomes confused the first thing that they should be assessed for is a UTI some older adults will not have a fever in fact they may exhibit low temperatures under 96.9 question 39 a nurse is observing a graduate nurse on orientation the grad nurse is educating the patient on the need for scds sequential compression devices which of the following statements by The Graduate nurse would warrant more education by the nurse a they help the blood in your legs recirculate to your heart B these will keep you from getting a blood clot after surgery C you do not have to wear them while you're sleeping D I will be coming to assess the pulses in your feet often the correct answer is C you do not have to wear them while you're sleeping scds should be worn anytime the patient is in bed this includes nighttime sleeping as well scds keep blood circulating in the bles and circulate it back to the heart for patients who move less while in the hospital question 40. a client is having a nephrostomy tube placed what is the best explanation for this patient to provide to this patient a this is to help drain your kidneys since you have a kidney stone blocking your ureter B this will help provide you with dialysis while you wait for your kidney transplant C this will help us give you antibiotics for your infection D this will help us drain your neck of any infectious drainage the correct answer is a this is to help drain your kidneys since you have a kidney stone blocking your ureter a nephrostomy tube is placed directly into the kidney to drain it of wastes urine when there is a blockage below the kidneys in the ureters keeping the urine from flowing into the bladder while one kidney May drain via the nephrostomy tube the other kidney can still drain into the bladder allowing the patient to still urinate thank you for watching this video we hope you enjoyed it click the first link in the description to take the free NCLEX practice test also check out these videos that can help you with your future studies don't forget to resuscitate the like button and subscribe to our Channel and please share this video with your fellow nursing friends

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Keywords: Reduction of Risk Potential questions, Reduction of Risk Potential nclex questions, nclex Reduction of Risk Potential questions, Reduction of Risk Potential nclex rn questions, Reduction of Risk Potential nclex rn, Reduction of Risk Potential nclex practice test answers, Reduction of Risk Potential nclex practice test answer key

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Length: 33min 43sec (2023 seconds)

Published: Mon Jun 19 2023