Clinical topic

NCLEX Reduction of Risk Potential questions

In short

The PrepScore bank has 138 Reduction of Risk Potential questions, each with a rationale and two tags: the Client Needs category from the test plan and the clinical judgment step it tests. In this topic the items lean on Generate solutions and Take action, which is worth knowing before you practise it. Three worked samples are below, answers behind a reveal.

Pre/post-op complications, transfusion reactions, central line management, critical labs, anticoagulation monitoring, chest tubes, tube feeding aspiration.

Three worked questions

Q1. A post-op pt suddenly reports a 'popping' sensation + bowel visible at the incision. The PRIORITY action is:

  • A. Push bowel back inside
  • B. Cover with sterile saline-soaked gauze + NPO + STAT surgery team
  • C. Apply firm dry pressure
  • D. Encourage ambulation
Show answer and rationale

Answer: Cover with sterile saline-soaked gauze + NPO + STAT surgery team

Evisceration emergency: cover with saline gauze, NPO, IV access, OR. NEVER push back.

Reduction of Risk PotentialStep: Take actionmedium

Q2. Which intervention BEST prevents post-op DVT in a moderate-risk client?

  • A. Bedrest until pain resolves
  • B. SCDs + early ambulation + appropriate prophylactic anticoagulation
  • C. Aspirin only
  • D. Compression hose alone
Show answer and rationale

Answer: SCDs + early ambulation + appropriate prophylactic anticoagulation

Post-op DVT prevention bundle (Virchow's triad mitigation): SCDs (mechanical — venous return) + early ambulation (movement) + appropriate prophylactic anticoagulation (LMWH or fondaparinux — hypercoagulability). Bedrest worsens stasis; aspirin alone insufficient for high-risk surgery; compression hose alone less effective than SCDs + pharmacologic combination.

Reduction of Risk PotentialStep: Generate solutionsfoundation

Q3. Which factors INCREASE the risk of pressure injury? Select all that apply.

  • A. Immobility
  • B. Incontinence + moisture
  • C. Adequate nutrition
  • D. Poor perfusion (shock, vasopressors)
  • E. Friction + shear
  • F. Daily skin assessment
Show answer and rationale

Answer: ImmobilityIncontinence + moisturePoor perfusion (shock, vasopressors)Friction + shear

PI risk: immobility + moisture + malnutrition + perfusion + friction. Nutrition + assessment are PROTECTIVE.

Reduction of Risk PotentialStep: Analyze cuesfoundation

The rules that decide these questions

From the pack's rule cards — the reasoning shortcuts a wrong answer usually means you were missing.

Pre-op NPO: coffee with cream = light meal, not clear liquid

Clear liquids are allowed up to 2 hours pre-op per ASA. Anything with fat (coffee with cream, milk, juice with pulp) is a LIGHT MEAL → 6-hour fast. Always report any pre-op intake honestly to anesthesia — the decision to delay or change technique is theirs.

Acute transfusion reaction: STOP, new tubing + NS, notify, send labs + unit back

Multi-system reaction in the first 15 minutes (fever + chills + flank pain + chest tightness + hypotension) = acute hemolytic transfusion reaction. STOP the blood immediately. Disconnect tubing and start a NEW IV / new tubing with 0.9% NS to keep access. Notify provider + blood bank. Send post-reaction labs (DAT, plasma free Hgb, urine for hemoglobin, CBC, coags), first voided urine, and return the unit + tubing to blood bank.

Air embolism after central line manipulation = LEFT side + Trendelenburg + clamp

Sudden dyspnea + chest pain + hypoxia after a central line is inserted, removed, or manipulated = air embolism. Position the patient LEFT lateral with head DOWN (Trendelenburg) — traps air in the right atrium. Clamp the catheter, cover insertion site with occlusive dressing, apply O2, call rapid response.

Evisceration: sterile saline-soaked gauze + low Fowler + knees flexed + NPO + OR

Visible bowel through a dehisced wound = evisceration. Cover with STERILE saline-soaked gauze (dry desiccates the bowel). Position low Fowler with knees flexed (reduces abdominal tension). NPO, IV access, call surgeon STAT for return to OR. NEVER push the bowel back in.

Chest tube disconnect: submerge in sterile water, do NOT clamp

An open chest tube allows air entry → tension pneumothorax risk. IMMEDIATELY submerge the disconnected end in sterile water 2 cm deep (instant water seal). Do NOT clamp — clamping with an air leak causes tension pneumothorax. Get a new sterile drainage system (pre-fill water seal), connect, reapply suction. Monitor for tension.

Critical labs: physiology + symptoms drive priority, not the worst number

Acuity is determined by physiology + symptoms, not lab number magnitude. Symptomatic hypoglycemia + hyperkalemia with ECG changes act in minutes. Symptomatic moderate hyponatremia in 30-60 min. Asymptomatic anemia in hours. Treat severe hypoglycemia at the bedside before calling — D50 first.

Practise the whole pack, tagged and explained

Every item carries its Client Needs category and clinical judgment step, so a wrong answer names the step that failed.

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Frequently asked questions

How many Reduction of Risk Potential questions does the bank have?

138 multiple-choice items, plus 10 unfolding cases in the Reduction of Risk Potential pack, each with a rationale.

Are the samples real bank items?

Yes — the three questions above are drawn from the live bank, with their real rationales and tags.

Which clinical judgment steps does this topic train?

Most items in this topic test Generate solutions and Take action, though every step appears.

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