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NCLEX RN· Reduction of Risk Potential · Reduction of Risk Potential RN Nursing

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Showing all 5 practice questions with expert explanatory rationales.

Question 1 of 5

The nurse is caring for a client in the cardiac unit and notices the client's rhythm changes from normal sinus rhythm to coarse ventricular fibrillation. Which is the priority nursing action?

A. call a code blue
B. check the client and check the leads
C. initiate CPR while waiting on help to arrive
D. prepare to start the client on a diltiazem (Cardizem) drip
E. clear the room of unnecessary items to allow room for the crash cart and team

Expert Explanatory Rationale

Correct Answer: initiate CPR while waiting on help to arrive

Question 2 of 5

A client is having a tonic-clonic seizure. Which of the following should the nurse do first?

A. call for assistance
B. restrain the client
C. turn the client on her side
D. provide a safe environment

Expert Explanatory Rationale

Correct Answer: provide a safe environment

Question 3 of 5

The nurse is performing discharging instruction for a female client with cystitis. Which statement by the client indicates a need for further teaching?

A. I should void before and after intercourse.
B. I should wear loose-fitting cotton underwear.
C. I can continue using spermicide for birth control.
D. If I have burning when I urinate, I will contact my physician.

Expert Explanatory Rationale

Correct Answer: I can continue using spermicide for birth control.

Question 4 of 5

The nurse is educating a client who has been ordered to wear a Holter monitor. Which statement by the client indicates a need for further education by the nurse?

A. I can wear the monitor while I shower.
B. I should keep the monitor on when I sleep.
C. I should avoid metal detectors and electric razors while wearing the monitor.
D. I should keep a log of any chest pain, shortness of breath, or skipped beats while wearing the monitor.

Expert Explanatory Rationale

Correct Answer: I can wear the monitor while I shower.

Question 5 of 5

The nurse is caring for an adult client with a total bilirubin of 2.1 mg/dL. Which signs and symptoms would the nurse expect to find? Select all that apply.

A. itchy skin
B. nausea
C. pale stools
D. colorless urine
E. none; this is a normal lab value

Expert Explanatory Rationale

Correct Answer:

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