NCLEX-PN Reduction of Risk Potential Practice Test

25 practice questions

Choose an answer, then check it under Show answer.

1. Question 1 of 25Medium

   A client who had a subtotal thyroidectomy 24 hours ago reports new numbness and tingling around the lips and fingers. Which laboratory finding is the most critical for the practical nurse to report to the healthcare provider?

   1. AA. Serum sodium of 137 mEq/L (137 mmol/L)
   2. BB. Total serum calcium of 6.8 mg/dL (1.70 mmol/L)
   3. CC. Serum magnesium of 2.0 mg/dL (0.82 mmol/L)
   4. DD. Serum potassium of 3.9 mEq/L (3.9 mmol/L)
   Show answer to question 1

   Answer: B. Total serum calcium of 6.8 mg/dL (1.70 mmol/L)

   Accidental damage or removal of the parathyroid glands during thyroid surgery can cause acute hypocalcemia, indicated by a serum calcium level well below the normal range of 8.5 to 10.5 mg/dL. Hypocalcemia manifests with circumoral paresthesias, tetany, and potential laryngospasm, requiring urgent intervention with intravenous calcium gluconate. A serum magnesium level of 2.0 mg/dL is within the normal reference range of 1.6 to 2.6 mg/dL and does not explain the acute symptoms.

2. Question 2 of 25Medium

   A nurse checks the oxygen saturation of a 71-year-old man with chronic obstructive pulmonary disease whose baseline is 94% on room air. The finger probe reads 84%. The client is relaxed, speaking in full sentences and has cold hands and dark nail polish. What should the nurse do next?

   1. AA. Warm the client's hand, reposition the probe on a bare nail, and recheck the reading.
   2. BB. Apply oxygen by mask at 10 L/min right away and recheck the saturation in 30 minutes.
   3. CC. Report critical hypoxemia to the provider immediately without taking any other steps first.
   4. DD. Document 84% as the client's usual saturation because of the chronic lung disease.
   Show answer to question 2

   Answer: A. Warm the client's hand, reposition the probe on a bare nail, and recheck the reading.

   Cold fingers and dark nail polish commonly cause falsely low readings. The nurse should correct these factors, recheck, and compare the result with the client's appearance and baseline.

   Why the other options are wrong

   • BHigh-flow oxygen given before verifying the reading is unnecessary and can be harmful in a client with chronic lung disease.
   • CReporting an unverified reading for a client who looks comfortable skips basic steps to confirm the data first.
   • DThe stated baseline is 94%, so 84% is not the client's usual value and should not be charted as normal.

3. Question 3 of 25Medium

   Which action by a nurse applying thigh-high antiembolism stockings to a client on the day after surgery is correct?

   1. AA. Apply the stockings after the client has been standing for 10 minutes.
   2. BB. Fold the top of each stocking down into a band at the knee.
   3. CC. Apply them before the client rises, with legs raised and wrinkles smoothed.
   4. DD. Leave them on continuously without removal for skin checks during the stay.
   Show answer to question 3

   Answer: C. Apply them before the client rises, with legs raised and wrinkles smoothed.

   Stockings are best applied when the legs are least swollen, such as before rising, and must be smooth. Wrinkles can restrict circulation and cause skin injury.

   Why the other options are wrong

   • AStanding allows blood to pool and the legs to swell, making correct application harder and less effective.
   • BA folded band can act like a tourniquet and restrict blood flow at the knee.
   • DStockings are removed per policy, usually daily, so the nurse can inspect the skin and assess circulation.

4. Question 4 of 25Medium

   A clinic nurse is reinforcing teaching with a 58-year-old man who will collect stool samples at home using a guaiac-based fecal occult blood test kit. Which instruction should the nurse include?

   1. AA. Avoid vitamin C supplements and red meat for several days before and during collection
   2. BB. Take a laxative the night before so that enough stool is available for each sample
   3. CC. Collect the stool from the toilet water so the specimen is well mixed with moisture
   4. DD. Fast for 12 hours before collecting each of the stool samples on the card
   Show answer to question 4

   Answer: A. Avoid vitamin C supplements and red meat for several days before and during collection

   Vitamin C can cause false negative results, and red meat can cause false positive results with guaiac-based tests, so both are avoided for several days.

   Why the other options are wrong

   • BLaxatives are not needed and can alter the specimen.
   • CStool in toilet water is diluted and contaminated, so it is not an acceptable sample.
   • DFasting is not required for this test.

5. Question 5 of 25Easy

   A nurse is reviewing serial vital signs recorded over the past 4 hours for a postoperative client: 0800: blood pressure 122/78 mm Hg, pulse 76/min, respirations 16/min; 1000: blood pressure 114/72 mm Hg, pulse 88/min, respirations 18/min; 1200: blood pressure 104/68 mm Hg, pulse 108/min, respirations 22/min. Which interpretation should the nurse make regarding this trend?

   1. AA. Expected cardiovascular stabilization following anesthesia recovery
   2. BB. Early compensatory response to hypovolemia or hemorrhage
   3. CC. Fluid volume overload secondary to rapid intravenous infusion
   4. DD. Gradual onset of neurogenic central nervous system depression
   Show answer to question 5

   Answer: B. Early compensatory response to hypovolemia or hemorrhage

   Tachycardia, a progressive increase in respiratory rate, and a gradual decrease in systolic blood pressure are hallmark compensatory signs of shock, such as from internal bleeding or fluid deficit. As stroke volume declines, the body compensates by increasing heart rate and systemic vascular resistance. Attributing this trend to expected postoperative stabilization is incorrect because progressive tachycardia and narrowing pressures signal physiological decline rather than recovery.

6. Question 6 of 25Medium

   A nurse is recording a 12-lead EKG on a 60-year-old man with chest discomfort. He is shivering and anxious, and the tracing shows a jagged, irregular baseline. What action should the nurse take?

   1. AA. Apply lotion to the skin under each electrode to improve signal contact.
   2. BB. Ask the client to hold his breath during the entire tracing recording.
   3. CC. Warm the client with a blanket, support his limbs, and repeat the tracing.
   4. DD. Submit the tracing as recorded and let the provider decide if it is usable.
   Show answer to question 6

   Answer: C. Warm the client with a blanket, support his limbs, and repeat the tracing.

   Shivering and tension cause muscle artifact. Warming the client, supporting the limbs and reassuring him reduce movement so a clean tracing can be obtained.

   Why the other options are wrong

   • ALotion and oils reduce electrode contact and increase artifact rather than improving the signal.
   • BHolding the breath for the whole recording is unsafe and increases muscle tension; the client should breathe normally.
   • DA poor-quality tracing may hide important findings, so the nurse should obtain a readable one before submitting it.

7. Question 7 of 25Medium

   A nurse in a prenatal clinic is collecting data from a client at 33 weeks of gestation. Which client report should the nurse communicate to the RN immediately?

   1. AA. Mild ankle swelling in the evening that improves overnight
   2. BB. Irregular painless tightening of the abdomen that stops with rest
   3. CC. Painless bright red vaginal bleeding that began this morning
   4. DD. Heartburn after large meals and mild fatigue by late afternoon
   Show answer to question 7

   Answer: C. Painless bright red vaginal bleeding that began this morning

   Painless bright red vaginal bleeding in the third trimester suggests a complication such as placenta previa and carries a risk of hemorrhage for the client and fetus.

   Why the other options are wrong

   • AMild dependent edema that resolves with rest is a common expected finding in late pregnancy.
   • BIrregular painless contractions that stop with rest are consistent with Braxton Hicks contractions.
   • DHeartburn and fatigue are common discomforts of late pregnancy and are not warning signs.

8. Question 8 of 25Easy

   A licensed practical nurse (LPN) is monitoring a client who received intravenous morphine 30 minutes ago. The client is difficult to arouse and has shallow respirations at a rate of 8 breaths/min. Which action should the nurse take first?

   1. AA. Recheck the client's vital signs and oxygen level in 30 minutes.
   2. BB. Vigorously stimulate the client to breathe and call for the registered nurse.
   3. CC. Place the client in a supine position with the lower extremities elevated.
   4. DD. Document the findings as an expected therapeutic effect of the opioid.
   Show answer to question 8

   Answer: B. Vigorously stimulate the client to breathe and call for the registered nurse.

   The immediate priority for a client with opioid-induced respiratory depression is to attempt verbal and physical stimulation to encourage breathing while quickly alerting the registered nurse or rapid response team. Placing the client supine with legs elevated is an intervention for hypotension, not respiratory depression, and delaying care by waiting 30 minutes puts the client at grave risk for respiratory arrest.

9. Question 9 of 25Hard

   A client who has a bowel obstruction has a nasogastric tube connected to low intermittent suction. The client reports new nausea, the abdomen is more distended, and no drainage has entered the canister in the past 2 hours. Which action should the nurse take first?

   1. AA. Turn off the suction and reassess the client in 1 hour
   2. BB. Pull out the tube and reinsert it in the other nostril
   3. CC. Check tubing for kinks or leaks and confirm suction works
   4. DD. Raise the suction to a high continuous setting to clear it
   Show answer to question 9

   Answer: C. Check tubing for kinks or leaks and confirm suction works

   Absent drainage with nausea and distention suggests the tube is not patent, so the nurse first checks the system for kinks, leaks and proper suction before reporting or irrigating per order.

   Why the other options are wrong

   • ATurning off the suction and waiting an hour delays relief and allows gastric contents to accumulate.
   • BPulling out and reinserting the tube is not done without an order and is not the first step.
   • DHigh continuous suction can injure the gastric mucosa and is not used unless prescribed.

10. Question 10 of 25Easy

    The nurse is reinforcing teaching with a client on the first day after abdominal surgery. Which instruction about coughing and deep breathing should the nurse include?

    1. AA. Take shallow breaths to protect the incision from strain
    2. BB. Cough only when you feel secretions in your throat
    3. CC. Lie flat on your back while practicing deep breaths
    4. DD. Hold a pillow firmly over the incision when you cough
    Show answer to question 10

    Answer: D. Hold a pillow firmly over the incision when you cough

    Splinting the incision with a pillow reduces pain and strain, so the client can cough effectively and prevent atelectasis and pneumonia.

    Why the other options are wrong

    • AShallow breathing allows alveoli to collapse and raises the risk of pneumonia.
    • BCoughing and deep breathing should be done on a regular schedule, not only when secretions are felt.
    • CSitting upright allows fuller lung expansion; lying flat limits it.

11. Question 11 of 25Easy

    A client who uses a continuous glucose monitor (CGM) reports feeling tremulous, diaphoretic, and dizzy. The CGM displays a glucose reading of 108 mg/dL with a stable horizontal arrow. Which action should the practical nurse take first?

    1. AA. Check the client's capillary blood glucose using a bedside fingerstick.
    2. BB. Recheck the monitor display in 15 minutes to assess the trend.
    3. CC. Recalibrate the continuous glucose monitor sensor device.
    4. DD. Provide the client with four ounces of fruit juice immediately.
    Show answer to question 11

    Answer: A. Check the client's capillary blood glucose using a bedside fingerstick.

    Continuous glucose monitors measure glucose in interstitial fluid, which has a 5- to 15-minute lag time compared to capillary blood. When clinical symptoms of hypoglycemia conflict with sensor readings, the nurse must immediately confirm blood glucose with a fingerstick capillary check. Providing juice before confirming is tempting, but fingerstick verification is required when symptoms do not match interstitial sensor data to determine exact treatment needs.

12. Question 12 of 25Easy

    A nurse is performing neurologic checks every hour on a client who was admitted after a fall with a head injury. Which finding is the earliest sign of increasing intracranial pressure?

    1. AA. New restlessness with decreased alertness
    2. BB. Widening pulse pressure with a slowing heart rate
    3. CC. One pupil that is dilated and fixed to light
    4. DD. Extension posturing in response to painful stimuli
    Show answer to question 12

    Answer: A. New restlessness with decreased alertness

    A change in level of consciousness, often beginning as restlessness or irritability, is the earliest and most sensitive indicator of rising intracranial pressure.

    Why the other options are wrong

    • BWidening pulse pressure with bradycardia is part of Cushing triad, which is a late sign of rising intracranial pressure.
    • CA dilated pupil that is fixed to light is a late sign and suggests brain herniation.
    • DExtension posturing indicates severe brain dysfunction and occurs late, not as an early sign.

13. Question 13 of 25Easy

    A client has just had a small-bore nasogastric (NG) tube inserted for enteral feedings. Which method is the most reliable for confirming placement before the first feeding is started?

    1. AA. Injecting air through the tube while listening over the stomach
    2. BB. Obtaining radiographic confirmation of the tube position
    3. CC. Placing the end of the tube in water and watching for bubbles
    4. DD. Asking the client to speak and checking for a normal voice
    Show answer to question 13

    Answer: B. Obtaining radiographic confirmation of the tube position

    An x-ray is the most reliable way to confirm initial placement of a newly inserted small-bore feeding tube, because other bedside methods can miss placement in the lungs.

    Why the other options are wrong

    • AThe air-whoosh test is unreliable because sounds from the lungs and stomach can be confused.
    • CBubbling in water is unreliable and can occur with a tube in the stomach or the airway.
    • DA normal voice does not exclude a tube in the airway, especially in a client with a reduced cough reflex.

14. Question 14 of 25Easy

    A nurse is reinforcing instructions with a client who is preparing to collect a stool sample at home for a guaiac fecal occult blood test. Which instruction should the nurse include?

    1. AA. Collect stool samples from two different areas of the bowel movement.
    2. BB. Refrigerate the test card for 48 hours before applying the developer.
    3. CC. Mix the stool sample thoroughly with toilet water before applying it.
    4. DD. Increase intake of red meat for three days before collecting the specimen.
    Show answer to question 14

    Answer: A. Collect stool samples from two different areas of the bowel movement.

    Taking stool samples from two distinct locations of the stool increases test accuracy by detecting blood that may not be distributed evenly throughout the specimen. Toilet bowl water can dilute or alter the specimen and should not mix with the stool sample. Red meat contains animal hemoglobin, which can cause false-positive results, so clients must avoid red meat for at least three days prior to testing.

15. Question 15 of 25Medium

    A nurse is reinforcing teaching with a client who needs to collect a sputum specimen for culture at home. Which instruction should the nurse give?

    1. AA. Brush with toothpaste and use antiseptic mouthwash right before collecting.
    2. BB. Spit saliva into the container after eating breakfast to avoid coughing.
    3. CC. Cough gently a few times at any hour and spit out whatever comes up.
    4. DD. Rinse with water, then cough deeply on waking and spit into the container.
    Show answer to question 15

    Answer: D. Rinse with water, then cough deeply on waking and spit into the container.

    An early morning specimen from a deep cough, after rinsing the mouth with water, contains secretions from the lungs with the least contamination from the mouth.

    Why the other options are wrong

    • AAntiseptic mouthwash can kill organisms and cause a false negative culture.
    • BSaliva is not sputum, and eating beforehand leaves food in the mouth that contaminates the specimen.
    • CA gentle cough produces mostly saliva rather than lower airway secretions, and collecting at any hour misses the early morning secretions.

16. Question 16 of 25Medium

    The nurse is inserting an indwelling urinary catheter in a 67-year-old female client. After advancing the catheter, no urine returns, and the nurse sees that the catheter is in the vaginal opening. What action should the nurse take?

    1. AA. Leave that catheter in place as a landmark and insert a new sterile catheter into the urethral meatus.
    2. BB. Remove the catheter, rinse it with sterile saline, and reinsert the same catheter into the urethra.
    3. CC. Advance the catheter several more inches to see whether urine begins to drain from the bladder.
    4. DD. Pull the catheter back slightly and redirect it upward without changing to a new catheter.
    Show answer to question 16

    Answer: A. Leave that catheter in place as a landmark and insert a new sterile catheter into the urethral meatus.

    A catheter placed in the vagina is contaminated. Leaving it as a landmark helps identify the vaginal opening, and a new sterile catheter must then be placed in the urethral meatus.

    Why the other options are wrong

    • BRinsing with saline does not make a contaminated catheter sterile, and reinserting it risks a urinary tract infection.
    • CAdvancing a catheter in the vagina will not reach the bladder and can injure tissue.
    • DRedirecting the same contaminated catheter breaks sterile technique and risks introducing organisms into the bladder.

17. Question 17 of 25Medium

    A clinic nurse is reinforcing teaching with a 58-year-old client who has hypertension and will check blood pressure at home. Which instruction should the nurse include?

    1. AA. Lie down in bed and let your arm hang off the side during the reading.
    2. BB. Check your pressure right after a brisk morning walk and a cup of coffee.
    3. CC. Sit with your legs crossed and rest your arm on your lap for the reading.
    4. DD. Sit quietly 5 minutes, back supported, feet flat, arm at heart level.
    Show answer to question 17

    Answer: D. Sit quietly 5 minutes, back supported, feet flat, arm at heart level.

    An accurate reading needs a rested client seated with back supported, feet flat and the arm supported at heart level, which avoids falsely high or low values.

    Why the other options are wrong

    • ALetting the arm hang below heart level gives a falsely high reading, and the client should be seated and rested instead.
    • BExercise and caffeine temporarily raise blood pressure, so a reading taken right afterward is misleading.
    • CCrossed legs and an arm resting on the lap, below heart level, falsely raise the reading.

18. Question 18 of 25Hard

    A practical nurse is monitoring a client 4 hours after a transurethral resection of the prostate (TURP) with continuous bladder irrigation. The nurse notes that irrigation fluid is infusing, but drainage into the collection bag has stopped and the client reports severe suprapubic pain. Which action should the nurse take first?

    1. AA. Increase the flow rate of the continuous irrigation solution.
    2. BB. Check the catheter tubing for kinks or blood clot obstruction.
    3. CC. Contact the healthcare provider to report bladder perforation.
    4. DD. Administer the prescribed PRN bladder antispasmodic medication.
    Show answer to question 18

    Answer: B. Check the catheter tubing for kinks or blood clot obstruction.

    A sudden stoppage of drainage accompanied by suprapubic cramping strongly indicates catheter obstruction, usually from kinks or blood clots. The nurse should immediately assess the tubing for mechanical kinks and patency before taking further action. Increasing the flow rate while an obstruction is present would rapidly distend the bladder and increase the risk of bladder rupture.

19. Question 19 of 25Medium

    A home health nurse is checking the fingerstick blood glucose of a 76-year-old woman with type 2 diabetes. Which action will best help ensure an accurate result?

    1. AA. Clean the site with alcohol and puncture it while the skin is still wet
    2. BB. Puncture the center of the fingertip pad, where blood flow is greatest
    3. CC. Squeeze the fingertip firmly after the puncture to obtain a large drop quickly
    4. DD. Have the client wash hands with warm soapy water and dry them completely first
    Show answer to question 19

    Answer: D. Have the client wash hands with warm soapy water and dry them completely first

    Washing with warm soapy water removes sugar residue and improves circulation, and drying completely prevents dilution of the sample, so the result is more accurate.

    Why the other options are wrong

    • AAlcohol that has not dried can dilute the blood sample and may alter the meter reading.
    • BThe sides of the fingertip are preferred because they are less painful and have good blood supply.
    • CHard squeezing mixes tissue fluid with blood and can produce an inaccurate reading.

20. Question 20 of 25Medium

    A client had an indwelling urinary catheter removed 6 hours ago after abdominal surgery. The client has not voided and reports lower abdominal discomfort. A bladder scan shows 550 mL of urine. Which action should the nurse take next?

    1. AA. Document the result and rescan the bladder at the start of next shift
    2. BB. Apply firm manual pressure over the lower abdomen to prompt voiding
    3. CC. Report the finding to the provider to obtain a catheterization order
    4. DD. Restrict oral fluids for several hours to decrease urine production
    Show answer to question 20

    Answer: C. Report the finding to the provider to obtain a catheterization order

    A scan volume of 550 mL with discomfort indicates urinary retention, which needs prompt reporting so that an order for catheterization can be obtained.

    Why the other options are wrong

    • AWaiting until the next shift allows bladder overdistention and possible bladder damage.
    • BManual pressure on the abdomen is not an appropriate independent intervention and can be harmful after surgery.
    • DRestricting fluids does not relieve retention and may lead to dehydration.

21. Question 21 of 25Hard

    A licensed practical nurse (LPN) is monitoring a client who has a peripherally inserted central catheter (PICC) in the right upper arm. Which finding requires immediate notification of the registered nurse (RN)?

    1. AA. The transparent dressing is dry, intact, and dated three days ago
    2. BB. Blood return is easily aspirated from the line prior to flushing
    3. CC. The client reports mild, brief coolness during the normal saline flush
    4. DD. The external catheter measurement at the exit site has increased by 4 centimeters
    Show answer to question 21

    Answer: D. The external catheter measurement at the exit site has increased by 4 centimeters

    An increase in the external catheter measurement indicates catheter migration or dislodgement, which means the tip may no longer reside in the superior vena cava. The LPN must report this immediately to the RN so catheter placement can be verified before further infusions are administered. Mild coolness during flushing and an intact dressing within standard change intervals are expected findings.

22. Question 22 of 25Hard

    A nurse in acute care is monitoring a 66-year-old client admitted after a fall with a head strike. At 0800 the client was alert, oriented, and had equal hand grips. At 1000 the client is drowsy, repeatedly asks the same question, and has a weaker right hand grip. Which action should the nurse take?

    1. AA. Let the client rest and repeat the neurologic checks at noon
    2. BB. Report the changes to the RN or provider now and continue neurologic checks
    3. CC. Reorient the client and document the findings as expected after a fall
    4. DD. Offer a snack and fluids, then reassess orientation after the client eats
    Show answer to question 22

    Answer: B. Report the changes to the RN or provider now and continue neurologic checks

    New drowsiness, confusion, and unilateral weakness compared with baseline suggest rising intracranial pressure or bleeding, so they need immediate reporting and ongoing close neurologic monitoring.

    Why the other options are wrong

    • AWaiting two hours delays recognition of a possible emergency, and sleep can hide further decline.
    • CThese changes are not expected after a head injury and should not simply be charted.
    • DHunger does not explain a weaker grip and drowsiness, and delaying the report risks harm.

23. Question 23 of 25Hard

    At the start of the shift, a nurse in a long-term care facility finds an 82-year-old resident who is usually alert, oriented and walking with a walker. The resident is now drowsy and oriented to person only, with new urinary incontinence, a temperature of 100.4 F (38 C), a pulse of 98 and a blood pressure of 104/60 mm Hg. The usual blood pressure is 130/78 mm Hg. Which action should the nurse take?

    1. AA. Document the confusion as normal for age and recheck next shift
    2. BB. Encourage oral fluids and plan to reassess the resident at noon
    3. CC. Ask assistive personnel to watch the resident and report decline
    4. DD. Report the change from baseline to the RN promptly using SBAR
    Show answer to question 23

    Answer: D. Report the change from baseline to the RN promptly using SBAR

    New confusion, fever, incontinence and a lower blood pressure compared with baseline suggest an acute problem such as infection. The nurse must report this change from baseline promptly so the RN can assess and act.

    Why the other options are wrong

    • ASudden confusion is not a normal part of aging, and waiting until the next shift delays care for a possible infection.
    • BFluids may help, but waiting until noon to reassess delays reporting and risks worsening of a possible infection.
    • CA resident with a changing condition needs nursing assessment and reporting, which should not be left to assistive personnel alone.

24. Question 24 of 25Hard

    An LPN in an outpatient clinic receives a telephone call from a client who had a contrast-enhanced CT scan 48 hours ago. The client reports developing a mild, itchy red rash across the arms and chest earlier today. Which response by the nurse is best?

    1. AA. "Explain that contrast reactions only occur during the injection, so this must be an infection."
    2. BB. "Instruct the client to apply rubbing alcohol to the rash and monitor it for one week."
    3. CC. "Advise the client that delayed skin reactions can occur and notify the provider for evaluation."
    4. DD. "Instruct the client to immediately go to the nearest emergency department by ambulance."
    Show answer to question 24

    Answer: C. "Advise the client that delayed skin reactions can occur and notify the provider for evaluation."

    Delayed hypersensitivity reactions to iodinated contrast media can appear hours to several days after exposure, commonly manifesting as mild cutaneous rashes or pruritus. The nurse should explain that delayed reactions are possible and report the findings to the RN or healthcare provider for symptomatic treatment. Immediate ambulance transport is unnecessary for a stable, mild rash without respiratory or hemodynamic compromise, and applying rubbing alcohol would cause skin irritation.

25. Question 25 of 25Hard

    A nurse is caring for a 68-year-old client on the first postoperative day after abdominal surgery. The client's usual blood pressure is 142/86. Now the blood pressure is 96/58, the heart rate is 118, and the skin is cool and pale. The client is restless. What is the nurse's best action?

    1. AA. Recheck the vital signs in one hour and continue the routine surgical care plan.
    2. BB. Encourage oral fluids and help the client walk in the hallway to improve circulation.
    3. CC. Stay with the client, recheck the vital signs, and report the changes to the RN right away.
    4. DD. Give a prescribed as-needed analgesic for restlessness and reassess the client in 30 minutes.
    Show answer to question 25

    Answer: C. Stay with the client, recheck the vital signs, and report the changes to the RN right away.

    Falling blood pressure, rapid pulse, cool skin and restlessness compared with baseline suggest bleeding or shock. The nurse confirms the findings and reports immediately because the client may be unstable.

    Why the other options are wrong

    • AWaiting an hour delays care for a client who may be hemorrhaging.
    • BWalking could cause fainting and a fall in a client with low blood pressure.
    • DRestlessness here is likely from poor perfusion, and giving an analgesic can mask the problem and lower blood pressure more.

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