Reduction of Risk Potential — NCLEX-RN practice questions

A client with a central line develops a fever, and blood cultures are pending. Which nursing action reflects appropriate central line-associated bloodstream infection (CLABSI) prevention while awaiting results?

1. Continue the routine dressing and flushing schedule without inspecting the site or changing technique, since the pending cultures will identify any infection
2. Assess the insertion site for redness/drainage, maintain strict aseptic technique for all line access, and follow facility CLABSI bundle protocols
3. Remove the central line immediately without further assessment, since any fever in a client with a central line confirms the line is the source
4. Increase the frequency of line access to draw additional specimens and check patency, so that more data are available when the provider is notified

Answer: B — Assess the insertion site for redness/drainage, maintain strict aseptic technique for all line access, and follow facility CLABSI bundle protocols

B) Correct — thorough site assessment and strict aseptic technique per CLABSI bundle protocols are appropriate ongoing prevention/evaluation steps. A) A fever with a central line present warrants increased vigilance. C) Removal decisions should follow clinical assessment/culture results and provider judgment. D) Minimizing unnecessary access reduces infection risk.

A patient on warfarin asks about diet. Which guidance is BEST?

1. Avoid all vitamin K-containing foods, including leafy greens, for as long as warfarin is prescribed
2. No specific dietary changes are needed, because warfarin works independently of the vitamin K obtained from food
3. Eat a large serving of spinach every day to keep vitamin K intake predictably high for the INR
4. Maintain a consistent intake of vitamin K-rich foods (leafy greens) — abrupt large changes alter INR

Answer: D — Maintain a consistent intake of vitamin K-rich foods (leafy greens) — abrupt large changes alter INR

Consistency is the goal, not avoidance. Sudden increases or decreases in vitamin K intake shift INR unpredictably. Teach moderation and consistency.

Which finding in a client with suspected carbon monoxide poisoning may be misleading if relying only on standard pulse oximetry?

1. SpO2 may read falsely normal/high despite significant hypoxia because pulse oximetry can't distinguish carboxyhemoglobin from oxyhemoglobin
2. SpO2 will always read accurately low because carboxyhemoglobin absorbs light differently than oxyhemoglobin at both wavelengths used
3. Pulse oximetry is the gold standard for diagnosing carbon monoxide poisoning and can replace co-oximetry or arterial blood gas testing
4. SpO2 readings are unaffected by carbon monoxide exposure because carboxyhemoglobin is cleared from the circulation before oximetry is performed

Answer: A — SpO2 may read falsely normal/high despite significant hypoxia because pulse oximetry can't distinguish carboxyhemoglobin from oxyhemoglobin

A) Correct — standard pulse oximetry cannot differentiate carboxyhemoglobin from oxyhemoglobin, giving falsely reassuring readings; co-oximetry or an ABG with carboxyhemoglobin level is needed. B) The opposite is true. C) Not the gold standard; can be misleading. D) Incorrect — CO exposure is exactly what causes the misleading reading.

A client returns from cardiac catheterization via the right femoral artery. Which assessment finding is MOST concerning?

1. Right pedal pulse weaker than left, with a cool, pale right foot
2. Blood pressure 128/74 with a regular heart rate of 78 and no complaints
3. Reports a mild back ache after lying flat for several hours
4. Insertion site dry and intact with a small surrounding ecchymosis

Answer: A — Right pedal pulse weaker than left, with a cool, pale right foot

A) Correct: diminished distal pulse, pallor, and coolness suggest arterial occlusion or thrombosis — a limb-threatening emergency requiring immediate provider notification. B) Stable vitals. C) Mild backache common from immobility. D) Small ecchymosis is expected.

A public health nurse is investigating a foodborne illness outbreak at a community event. Which action is the PRIORITY first step?

1. Close all restaurants in the area immediately, before any exposure information has been gathered
2. Withhold all investigative action until every laboratory specimen result has been finalized
3. Interview affected individuals to identify common food exposures and establish a case definition
4. Report the most likely pathogen based on reported symptoms alone, without interviewing those affected

Answer: C — Interview affected individuals to identify common food exposures and establish a case definition

C) Correct — establishing a case definition and identifying common exposures through interviews is the foundational first step of an outbreak investigation. A) Premature without identifying the actual source. B) Delaying action for full lab confirmation can allow ongoing exposure. D) Assumptions without investigation risk missing the true source.

A client with cirrhosis develops new confusion and asterixis. Which lab value MOST LIKELY accounts for these findings?

1. Elevated AST/ALT
2. Elevated total bilirubin
3. Low albumin
4. Elevated serum ammonia

Answer: D — Elevated serum ammonia

D) Correct: hepatic encephalopathy is driven by elevated ammonia; treatment includes lactulose. A) Transaminases mark hepatocyte injury but do not correlate well with mental status. C) Low albumin contributes to edema/ascites, not encephalopathy. B) Bilirubin reflects clearance but not mental status directly.

A client recovering from surgery has not voided 8 hours after Foley removal. Which assessment finding BEST indicates urinary retention requiring intervention?

1. Reports a feeling of urgency without ability to void; bladder scan shows 500 mL
2. Reports drinking about 200 mL of water in the past hour and feels no bladder discomfort
3. Has a soft, non-distended abdomen with active bowel sounds in all quadrants
4. Blood pressure 118/76 with a heart rate of 72 and no reported suprapubic pain

Answer: A — Reports a feeling of urgency without ability to void; bladder scan shows 500 mL

A) Correct: a bladder volume of ≥300-500 mL with inability to void is diagnostic of acute retention requiring intermittent catheterization. B) Intake alone does not confirm retention. C) Non-distended abdomen does not rule out retention; bladder scan is definitive. D) Stable vital signs are reassuring but not diagnostic.

A client is admitted with acute MI. Which combination of interventions reflects evidence-based initial care? SELECT ALL THAT APPLY.

1. Administer aspirin (chewed) unless contraindicated
2. Obtain a 12-lead EKG within 10 minutes of presentation
3. Administer high-flow oxygen via non-rebreather to every client regardless of SpO2
4. Establish IV access and obtain cardiac biomarkers
5. Administer sublingual nitroglycerin unless contraindicated (e.g., recent PDE5 inhibitor use, right ventricular infarct, hypotension)
6. F) Prepare for reperfusion (PCI within 90 minutes for STEMI)

Answer: ABDEF

Correct: A, B, D, E, F. A) Aspirin reduces mortality. B) Early EKG drives reperfusion timing. D) IV access + biomarkers are standard. E) Nitroglycerin with the appropriate contraindication checks. F) Door-to-balloon ≤ 90 min for STEMI. C) Wrong — current guidance reserves supplemental oxygen for SpO2 < 90%; routine high-flow oxygen in normoxic ACS patients can be harmful.

Normal adult vital signs?

BP <120/80, HR 60-100, RR 12-20, Temp 97-99°F (36.1-37.2°C), SpO2 95-100%.

Chest tube — normal vs abnormal water-seal findings?

Tidaling with respirations is normal; continuous bubbling indicates an air leak; keep the drainage system below chest level.