2. REDUCTION OF RISK
POTENTIAL
• Reduction of risk potential
involves ways in which you can
help to reduce the likelihood that
clients will develop complications
or health problems related to
existing conditions, diagnostic
tests, treatments, or other
procedures.
3. REDUCTION OF
RISK POTENTIAL
• On the NCLEX-RN® exam,
you can expect 12 percent
of the questions to relate
to Reduction of Risk
Potential.
4. Category includes
Changes/abnormalit
ies in vital signs
Diagnostic tests Laboratory values
Potential for
alterations in body
systems
Potential for
complications of
diagnostic
tests/treatments/pr
ocedures
Potential for
complications from
surgical procedures
and health
alterations
System specific
assessments
Therapeutic
procedures
5. Changes/Abnormalities in Vital Signs
You must be able to
assess client vital signs
and intervene when
those vital signs are
abnormal. Abnormal
vital signs include fever,
hypertension,
bradycardia, and
tachypnea.
In order to properly
assess vital signs and
recognize abnormalities,
apply your knowledge of
the client’s
pathophysiology.
Evaluate invasive
monitoring data, such as
pulmonary artery
pressure and intracranial
pressure
6. Diagnostic Tests
It is important to understand
the general principles of
specimen collection.
Ideally, routine specimen
collection should take place
early morning before a client
has any food or fluids.
If fasting is required, it is
usually for an 8–12-hour
period prior to the test.
Use standard precautions
and aseptic techniques to
protect yourself and your
clients from infection.
8. Potential for Alterations in Body Systems
It is important to be able to compare current
client data to baseline client data, particularly
to evaluate symptoms of illness/disease.
Identify client potential for aspiration (e.g.,
feeding tube, sedation, and swallowing
difficulties), skin breakdown potential due to
immobility, nutritional status or incontinence,
and clients with an increased risk for
insufficient vascular perfusion (such as clients
with immobilized limbs, who are postsurgery,
or who have diabetes).
You should also be able to provide treatments
and/or care in response. Monitor client output
for changes from baseline (nasogastric tube,
emesis, stools, and urine) and educate clients
about methods to prevent complications
associated with activity level or diagnosed
illness/disease (such as contractures, and foot
care for client with diabetes mellitus)
9. Potential for Complications of Diagnostic
Tests/Treatments/Procedures
You must assess a client
for complications or
abnormal responses
following a diagnostic test
or procedure, such as
monitoring the client for
signs of bleeding.
Know how to position
clients to prevent
complications following
tests, treatments, and
procedures, by, for
example, elevating the
head of the bed or
immobilizing an extremity.
When you see a
complication, it is
important to recommend
a change in tests,
procedures, and/or
treatment prescriptions
based on the client’s
response to the initial
testing and treatment.
11. System-specific Assessments
Assess clients for abnormal
peripheral pulses and
neurological status a
procedure or treatment.
Neurological status can be
assessed by checking level of
consciousness and evaluating
muscle strength and mobility.
Should also be able to assess
clients for peripheral edema,
hypoglycemia, and
hyperglycemia. It is also
important to identify factors
that could result in delayed
wound healing and to
implement appropriate
treatment in response,
and/or to notify the primary
care provider
12. Therapeutic
Procedures
• When caring for clients
undergoing therapeutic
procedures, assess client response
to recovery from local, regional, or
general anesthesia.
• Educate clients about treatments
and procedures, and home
management and care.
• The education may include
preoperative and/or postoperative
instructions to clients and families.
Monitor a client before, during,
and a
13. The nurse reviews the
medical record of a
client after surgery for
removal of the
parathyroid glands. The
client reports difficulty
swallowing and a feeling
of “pins and needles.”
Which of these
laboratory values is
consistent with this
finding?
(A) Decreased calcium.
(B) Increased lipase.
(C) Decreased potassium.
(D) Increased sodium.
14. The nurse reviews the
medical record of a
client after surgery for
removal of the
parathyroid glands. The
client reports difficulty
swallowing and a feeling
of “pins and needles.”
Which of these
laboratory values is
consistent with this
finding?
(A) Decreased calcium.
(B) Increased lipase.
(C) Decreased potassium.
(D) Increased sodium.
15. The nurse assesses a
pregnant client who
has tested positive
for gonorrhea.
Which of these
medications should
the nurse expect to
be part of the
treatment plan?
(A) Tetracycline.
(B) Ciprofloxacin.
(C) Azithromycin.
(D) Ceftriazona
16. The nurse assesses a
pregnant client who
has tested positive
for gonorrhea.
Which of these
medications should
the nurse expect to
be part of the
treatment plan?
(A) Tetracycline.
(B) Ciprofloxacin.
(C) Azithromycin.
(D) Ceftriazona
17. A client is one day post-
op for abdominal
surgery. The nurse
teaches the client
techniques to reduce
pain when moving,
coughing, or deep
breathing. Which client
statement indicates to
the nurse an accurate
understanding of the
information presented?
(A)“I can start exercising my limbs
as soon as you medicate me.”
(B) “I will just lie here for a few
days until the pain goes away.”
(C) “I will use the side rail for
support when I move or turn.”
(D) “I will ask for pain medication
only when necessary.”
18. A client is one day post-
op for abdominal
surgery. The nurse
teaches the client
techniques to reduce
pain when moving,
coughing, or deep
breathing. Which client
statement indicates to
the nurse an accurate
understanding of the
information presented?
(A)“I can start exercising my limbs
as soon as you medicate me.”
(B) “I will just lie here for a few
days until the pain goes away.”
(C) “I will use the side rail for
support when I move or turn.”
(D) “I will ask for pain medication
only when necessary.”
19. A 36-year-old
primigravid client
with a history of
diabetes mellitus
is admitted with
preeclampsia.
Which of the
following actions
should the nurse
take first? Prepare Prepare the client for childbirth.
Monitor Monitor the client’s blood pressure.
Ask Ask the provider to prescribe calcium
supplements.
Administer Administer low-dose aspirin as prescribed.
20. A 36-year-old
primigravid client
with a history of
diabetes mellitus
is admitted with
preeclampsia.
Which of the
following actions
should the nurse
take first? Prepare Prepare the client for childbirth.
Monitor Monitor the client’s blood pressure.
Ask Ask the provider to prescribe calcium
supplements.
Administer Administer low-dose aspirin as prescribed.
21. The nurse answers a call
light from a client who is
two days post-op for
abdominal surgery. The
client states, “I coughed
and heard this pop.”
The nurse assesses the
surgical site and
observes dehiscence of
the wound. Which of
these should the nurse
do first?
Stay
Stay with
the client
and have a
colleague
notify the
provider.
Help
Help the
client to lie
with his
head
slightly
elevated
and with
knees bent.
Apply
Apply
warm,
sterile
normal
saline soaks
over the
operative
wound.
Help
Help the
client to sit
upright, and
obtain a full
set of vital
signs.
22. The nurse answers a call
light from a client who is
two days post-op for
abdominal surgery. The
client states, “I coughed
and heard this pop.”
The nurse assesses the
surgical site and
observes dehiscence of
the wound. Which of
these should the nurse
do first?
Stay
Stay with
the client
and have a
colleague
notify the
provider.
Help
Help the
client to lie
with his
head
slightly
elevated
and with
knees bent.
Apply
Apply
warm,
sterile
normal
saline soaks
over the
operative
wound.
Help
Help the
client to sit
upright, and
obtain a full
set of vital
signs.
23. A client with a history
of myasthenia gravis
is admitted to the
medical-surgical unit.
Which of these tests
should the nurse
expect to be
prescribed for this
client? Select all that
apply.
(A) Tensilon test.
(B) Nerve conduction studies.
(C) Lumbar puncture.
(D) Electroencephalogram (EEG).
(E) Electromyography (EMG).
24. A client with a history
of myasthenia gravis
is admitted to the
medical-surgical unit.
Which of these tests
should the nurse
expect to be
prescribed for this
client? Select all that
apply.
(A) Tensilon test.
(B) Nerve conduction studies.
(C) Lumbar puncture.
(D) Electroencephalogram (EEG).
(E) Electromyography (EMG).
25. A client with a history
of atherosclerosis
reports abdominal
tenderness during
deep palpation. The
nurse notices a
pulsating mass in the
periumbilical area.
Which of these does
the nurse suspect?
(A) Appendicitis.
(B) Abdominal aortic aneurysm.
(C) Acute cholecystitis.
(D) Paralytic ileus.
26. A client with a history
of atherosclerosis
reports abdominal
tenderness during
deep palpation. The
nurse notices a
pulsating mass in the
periumbilical area.
Which of these does
the nurse suspect?
(A) Appendicitis.
(B) Abdominal aortic aneurysm.
(C) Acute cholecystitis.
(D) Paralytic ileus.
27. The laboratory values
of a client reveal the
presence of hepatitis
B surface antigens and
hepatitis B antibodies.
Which of these
laboratory results
should the nurse also
expect to see? Select
all that apply.
(A) Elevated serum albumin.
(B) Decreased serum globulin.
(C) Elevated serum transaminate (ALT and
AST).
(D) Prolonged prothrombin time (PT).
(E) Decreased urine bilirubin.
28. The laboratory values
of a client reveal the
presence of hepatitis
B surface antigens and
hepatitis B antibodies.
Which of these
laboratory results
should the nurse also
expect to see? Select
all that apply.
(A) Elevated serum albumin.
(B) Decreased serum globulin.
(C) Elevated serum transaminate (ALT and
AST).
(D) Prolonged prothrombin time (PT).
(E) Decreased urine bilirubin.
29. A client is recovering
from chronic
glomerulonephritis.
The nurse prepares
the client for
discharge and home
management. Which
of these statements
indicates the client
understands the
treatment plan of
chronic
glomerulonephritis?
“I should stop taking my blood pressure
medication if I feel better or have side effects.”
“I will take my furosemide medications as
ordered every morning.”
“I will keep my negative feelings to myself, so I
don’t get stressed.”
“I don’t need a follow-up examination unless
I’m feeling poorly.
30. A client is recovering
from chronic
glomerulonephritis.
The nurse prepares
the client for
discharge and home
management. Which
of these statements
indicates the client
understands the
treatment plan of
chronic
glomerulonephritis?
“I should stop taking my blood pressure
medication if I feel better or have side effects.”
“I will take my furosemide medications as
ordered every morning.”
“I will keep my negative feelings to myself, so I
don’t get stressed.”
“I don’t need a follow-up examination unless
I’m feeling poorly.
31. The provider
prescribes a CT
scan of the
client’s chest
with IV contrast.
Which of these
findings in the
client’s history
should the nurse
report to the
provider?
(A) Hypertension.
(B) Allergy to shellfish.
(C) Urinary tract infection (UTI).
(D) Allergy to penicillin.
32. The provider
prescribes a CT
scan of the
client’s chest
with IV contrast.
Which of these
findings in the
client’s history
should the nurse
report to the
provider?
(A) Hypertension.
(B) Allergy to shellfish.
(C) Urinary tract infection (UTI).
(D) Allergy to penicillin.
33. The nurse
performs an
assessment on a
client who has
cirrhosis. Which
of these signs
and symptoms
should the nurse
expect to see?
Select all that
apply.
(A) Dull abdominal ache.
(B) Cyanosis.
(C) Poor tissue turgor.
(D) Bruises.
(E) Fruity breath.
34. The nurse
performs an
assessment on a
client who has
cirrhosis. Which
of these signs
and symptoms
should the nurse
expect to see?
Select all that
apply.
(A) Dull abdominal ache.
(B) Cyanosis.
(C) Poor tissue turgor.
(D) Bruises.
(E) Fruity breath.
