NCLEX-RN Reduction of Risk Potential Exam

A client with suspected Cushing syndrome is given an order for a 24-hour urine cortisol test. The nurse is providing instructions on proper collection procedures and precautions to be followed while the client is home.

> Which client statement indicates the need for further instruction?

A 70-year-old client presents to the clinic complaining about urinary changes. Based on the client’s history, the nurse suspects benign prostatic hyperplasia (BPH).

> Which assessment finding is most consistent with early symptoms of benign prostatic hyperplasia?

The nurse reviews fasting serum glucose values for a client seen during a routine health screening.

> Which value is considered within normal limits?

A client admitted for major depressive disorder initially displayed withdrawal, flat affect, and verbalized feelings of worthlessness. On the fourth hospital day, the client appears suddenly upbeat, calm, and expresses relief.

> What is the nurse’s priority action?

The nurse is monitoring a laboring client experiencing shoulder dystocia.

> Which finding most strongly suggests clinical compromise?

A client is discharged after removal of a cervical radiation implant used to treat cancer.

> Which statement by the client indicates need for further instruction?

A client has an abdominal incision with a Penrose drain in place. The nurse plans care for the drain.

> Which nursing intervention is appropriate?

A nursing student needs to obtain a urine specimen from a 7-month-old infant for routine urinalysis.

> Which method should the student use?

A home care nurse visits a client who was discharged with axillary crutches after a minor ankle injury. During assessment, the nurse learns the client has a severe latex allergy. The crutches have rubber pads under the arms and on the tips.

> What should the nurse do first before teaching crutch use?

A pregnant client with a known history of genital herpes asks what will be done to protect the newborn from infection during delivery.

> Which instruction should the nurse provide?

A client presents with acute pain and swelling in the right great toe consistent with gout. Laboratory work is reviewed.

> Which value would the nurse expect?

A client comes to an urgent care clinic 2 days after a needlestick exposure at work and requests HIV testing “so I can stop worrying.” The initial screening test is negative, and the client says, “Great, that means I’m in the clear.”

> What should the nurse emphasize about these results?

A client is 48 hours post–spinal cord injury and has a nasogastric tube to low intermittent suction due to decreased bowel motility. The nurse monitors for gastrointestinal complications common after acute spinal cord injury.

> Which finding would be most concerning?

A nurse is caring for a client with a chest tube connected to a closed chest drainage system.

> Which nursing action is appropriate?

A client is hospitalized with dehydration from a UTI and is receiving IV fluids. The nurse is monitoring BUN to evaluate volume repletion.

> Which BUN value best suggests the client has received adequate volume replacement?

A client is transferred to the postop unit following rhinoplasty, with a nasal splint and a “moustache” dressing.

> Which position should the nurse anticipate as ordered?

The nurse is assessing four clients who are 24 hours postpartum.

> Which client finding requires follow-up?

> Which clients should be monitored most closely for development of urosepsis? Select all that apply.

A client calls after brushing against poison ivy about 20 minutes ago. The skin looks normal and the client asks what to do now.

> What should the nurse recommend?

A client arrives after a penetrating eye injury. A metal fragment is visibly protruding from the right eye.

> What should the nurse do first?