NCLEX-RN Reduction of Risk Potential Practice Test

25 practice questions

Choose an answer, then check it under Show answer.

1. Question 1 of 25Medium

   The nurse is reviewing the morning medication record for an adult client with type 2 diabetes mellitus who is NPO for an elective colonoscopy scheduled at 10:00. The client's 07:00 fingerstick capillary glucose level is 138 mg/dL (7.7 mmol/L). The client is scheduled to receive glimepiride 2 mg orally at 08:00. Which action should the nurse take?

   1. AA. Request a prescription to administer regular insulin intravenously.
   2. BB. Administer half the glimepiride dose to prevent rebound hyperglycemia.
   3. CC. Hold the glimepiride and document the blood glucose level.
   4. DD. Administer the glimepiride with a small sip of water.
   Show answer to question 1

   Answer: C. Hold the glimepiride and document the blood glucose level.

   Oral sulfonylureas such as glimepiride stimulate endogenous insulin secretion and should be held when a client is NPO to avoid profound hypoglycemia. Administering the medication or a halved dose without concurrent nutritional intake puts the client at serious risk for low blood glucose during the procedure. Intravenous insulin is not indicated because the client's blood glucose is within an acceptable target range and no carbohydrates are being consumed.

2. Question 2 of 25Medium

   A 16-year-old client is in the pediatric intensive care unit with a cerebral contusion from a skateboarding fall. During a neurologic check, the client opens the eyes only when the nurse speaks loudly, says random words such as "ball" and "mom" that do not answer the nurse's questions, and reaches up to push the nurse's hand away when the nurse applies pressure to the trapezius muscle. Which Glasgow Coma Scale (GCS) score should the nurse record?

   1. AA. 9
   2. BB. 11
   3. CC. 12
   4. DD. 13
   Show answer to question 2

   Answer: B. 11

   The eyes open to sound (E3), the client speaks inappropriate words that do not form a conversation (V3), and the client moves a hand to the site of the stimulus to push it away, which is localizing (M5). The total is 3 + 3 + 5 = 11.

   Why the other options are wrong

   • AA score of 9 would need lower responses, such as eye opening only to pressure together with withdrawal rather than localizing.
   • CA score of 12 would need confused but conversational speech (V4), and this client is not conversing.
   • DA score of 13 would need at least two higher responses, such as spontaneous eye opening plus confused conversation.

3. Question 3 of 25Medium

   A nurse is caring for a client in the postanesthesia care unit following a left carotid endarterectomy. Which assessment finding requires immediate escalation to the surgical team?

   1. AA. Hypoactive bowel sounds and mild post-procedure nausea
   2. BB. Rapidly increasing neck circumference with tracheal deviation
   3. CC. Blood pressure of 132/82 mm Hg and heart rate of 76 beats/min
   4. DD. Incisional tenderness rated as 3 on a 0-to-10 pain scale
   Show answer to question 3

   Answer: B. Rapidly increasing neck circumference with tracheal deviation

   An expanding neck hematoma following a carotid endarterectomy can rapidly compress the trachea and cause life-threatening airway compromise, evidenced by increasing neck circumference, stridor, or tracheal deviation. Mild incisional pain is expected and managed with prescribed analgesics. Normotensive blood pressure readings and mild postoperative nausea are common and do not indicate immediate surgical emergencies.

4. Question 4 of 25Medium

   A 55-year-old client with a paralytic ileus has a double-lumen sump nasogastric tube connected to low continuous suction. Which observation indicates that the tube is functioning correctly?

   1. AA. Gastric fluid is flowing out of the blue vent lumen.
   2. BB. The blue vent lumen is clamped to keep suction strong.
   3. CC. A soft hissing sound comes from the blue vent lumen.
   4. DD. The vent lumen and main lumen are both attached to suction.
   Show answer to question 4

   Answer: C. A soft hissing sound comes from the blue vent lumen.

   The vent lumen lets air enter the stomach so the suction does not pull the gastric lining against the tube; a soft hissing sound shows that air is moving freely through the vent.

   Why the other options are wrong

   • AFluid in the vent suggests the main lumen is not draining well; air is flushed into the vent and it is kept above stomach level.
   • BClamping the vent stops airflow and allows the tube to adhere to and injure the stomach lining.
   • DThe vent must stay open to air rather than being connected to suction.

5. Question 5 of 25Medium

   A nurse is teaching a client with type 2 diabetes mellitus managed with morning glipizide who is starting a clear liquid diet and bowel preparation for a colonoscopy scheduled for 0900 tomorrow. Which instruction regarding the glipizide is most appropriate?

   1. AA. Take a double dose of glipizide tomorrow morning to prevent rebound hyperglycemia.
   2. BB. Take the usual morning glipizide with a small glass of orange juice before arriving.
   3. CC. Switch glipizide to short-acting insulin during the clear liquid phase of the prep.
   4. DD. Withhold the morning dose of glipizide tomorrow while fasting before the procedure.
   Show answer to question 5

   Answer: D. Withhold the morning dose of glipizide tomorrow while fasting before the procedure.

   Oral sulfonylureas like glipizide stimulate insulin secretion; taking them while fasting (NPO) before a morning procedure markedly increases the risk of severe hypoglycemia, so morning doses are withheld until after the procedure when eating resumes. Administering a double dose or taking it with orange juice violates fasting guidelines and induces dangerous glycemic swings.

6. Question 6 of 25Easy

   A client is prescribed oral rivaroxaban for the treatment of deep vein thrombosis. Which laboratory assessment is most important for the nurse to monitor to evaluate medication safety?

   1. AA. Serum creatinine and estimated glomerular filtration rate
   2. BB. Weekly international normalized ratio
   3. CC. Daily activated partial thromboplastin time
   4. DD. Monthly plasma fibrinogen concentration
   Show answer to question 6

   Answer: A. Serum creatinine and estimated glomerular filtration rate

   Direct factor Xa inhibitors such as rivaroxaban do not require routine coagulation monitoring such as INR or aPTT. However, because rivaroxaban is eliminated partly by the kidneys, declining renal function increases drug levels and bleeding risk, making renal function monitoring essential. Routine INR monitoring is used for warfarin rather than direct oral anticoagulants.

7. Question 7 of 25Easy

   A nurse is completing a preoperative assessment for a client scheduled for an exploratory laparotomy. Which reported food allergy is most important for the nurse to communicate to the surgical team?

   1. AA. Bananas
   2. BB. Shellfish
   3. CC. Strawberries
   4. DD. Peanuts
   Show answer to question 7

   Answer: A. Bananas

   An allergy to bananas, avocados, kiwis, or chestnuts indicates a potential cross-sensitivity to natural rubber latex. Identifying this risk preoperatively is essential so the surgical team can prepare a latex-safe operating environment. An allergy to shellfish is historically discussed regarding radiopaque contrast media rather than natural rubber latex.

8. Question 8 of 25Medium

   A client is in the post-procedure unit with a pneumatic compression band in place over the right radial artery following a coronary intervention. The nurse observes that the right fingers are cool and pale, with a capillary refill time of 4 seconds and a report of thumb numbness. Which action should the nurse take first?

   1. AA. Administer the prescribed intravenous pain medication for numbness
   2. BB. Loosen the compression band incrementally according to protocol
   3. CC. Elevate the right arm above the level of the heart on two pillows
   4. DD. Place a warm blanket over the right forearm to relieve vasospasm
   Show answer to question 8

   Answer: B. Loosen the compression band incrementally according to protocol

   Signs of compromised distal perfusion and nerve compression after radial artery cannulation indicate that the compression device is inflated too tightly, causing arterial occlusion. The nurse should immediately loosen the band incrementally to restore patent blood flow while maintaining adequate hemostasis. Applying warmth or elevating the extremity delays relief of mechanical arterial obstruction and does not correct the underlying excessive pressure.

9. Question 9 of 25Medium

   A nurse is monitoring a client who underwent an uncomplicated vaginal delivery 90 minutes ago. Which assessment finding is the most sensitive early indicator of excessive postpartum bleeding?

   1. AA. Continuous, slow trickle of bright red vaginal blood
   2. BB. Systolic blood pressure dropping below 90 mm Hg
   3. CC. Saturation of one perineal pad over a 3-hour period
   4. DD. Hourly urine output decreasing to 28 mL/hr
   Show answer to question 9

   Answer: A. Continuous, slow trickle of bright red vaginal blood

   A continuous, steady trickle of bright red blood, even in the absence of massive visible expulsion, can rapidly deplete blood volume and represents an early sign of postpartum hemorrhage or genital tract laceration. Systemic hypotension is a late sign of hypovolemia in postpartum clients because compensatory hemodynamic mechanisms maintain blood pressure until up to 30% to 40% of blood volume is lost.

10. Question 10 of 25Medium

    A 4-month-old infant is admitted to the pediatric unit with irritability and poor feeding. The parent has been adding extra water to the infant's formula for the past week to make it last longer. The serum sodium is 121 mEq/L (reference 135 to 145 mEq/L). Which intervention should the nurse include in the plan of care?

    1. AA. Offer bottles of plain water between feedings.
    2. BB. Weigh the infant once a week to track fluid status.
    3. CC. Prepare to give an IV bolus of 5% dextrose in water.
    4. DD. Implement seizure precautions at the bedside.
    Show answer to question 10

    Answer: D. Implement seizure precautions at the bedside.

    A sodium of 121 mEq/L from water intoxication causes brain cell swelling and places the infant at high risk for seizures, so seizure precautions are needed while the sodium is corrected gradually.

    Why the other options are wrong

    • AExtra free water would lower the sodium further.
    • BFluid balance in an acutely ill infant is tracked with daily weights and intake and output, not weekly weights.
    • CDextrose 5% in water acts as free water once the glucose is used and would worsen the hyponatremia.

11. Question 11 of 25Medium

    A client who recently returned to the recovery area after an elective bronchoscopy develops sudden tachypnea, intercostal retractions, and a high-pitched inspiratory sound heard without a stethoscope. Which action should the nurse perform first?

    1. AA. Apply high-flow oxygen and prepare for emergency airway support.
    2. BB. Encourage slow, deep breathing into a closed paper bag.
    3. CC. Administer oral diphenhydramine to relieve mucosal edema.
    4. DD. Place the client supine and initiate chest physiotherapy.
    Show answer to question 11

    Answer: A. Apply high-flow oxygen and prepare for emergency airway support.

    A high-pitched inspiratory sound indicates stridor, which is a sign of acute laryngospasm or severe upper airway edema that can rapidly progress to complete airway occlusion. The priority action is to apply supplemental oxygen and prepare for emergency airway interventions, such as racemic epinephrine administration or endotracheal intubation. Placing the client supine impairs airway patency and gas exchange, while oral medications are contraindicated during an acute airway emergency.

12. Question 12 of 25Hard

    A nurse is assessing four clients who received intravenous contrast media within the past 15 minutes. Which client is exhibiting signs of an allergic-like hypersensitivity reaction that requires prompt evaluation for medical treatment?

    1. AA. A client with a warm sensation spreading across the chest and abdomen
    2. BB. A client with a heart rate of 52 beats/min and mild lightheadedness
    3. CC. A client with a single episode of non-bloody, watery emesis
    4. DD. A client with scattered pruritic wheals on the neck and torso
    Show answer to question 12

    Answer: D. A client with scattered pruritic wheals on the neck and torso

    Pruritic wheals (urticaria) are classic cutaneous signs of an allergic-like (anaphylactoid) reaction to contrast media and require prompt evaluation, monitoring, and likely antihistamine therapy. Nausea, vomiting, and warmth are non-allergic chemotoxic reactions, whereas bradycardia with lightheadedness suggests a vasovagal response rather than a hypersensitivity reaction.

13. Question 13 of 25Medium

    A 58-year-old client is scheduled for an elective laparoscopic cholecystectomy in the morning. The nurse reviews the preoperative orders and notes that the client takes metformin 1000 mg orally twice daily for type 2 diabetes. Which preoperative instruction should the nurse clarify with the prescribing provider?

    1. AA. Take the morning dose of metformin with a sip of water on the day of surgery.
    2. BB. Continue the metformin as usual until midnight before surgery.
    3. CC. Hold all oral antidiabetic medications 24 hours before the procedure.
    4. DD. Take half the usual dose of metformin on the evening before surgery.
    Show answer to question 13

    Answer: A. Take the morning dose of metformin with a sip of water on the day of surgery.

    Metformin is usually held on the morning of surgery because fasting and surgical stress increase the risk of lactic acidosis. An instruction to take the morning dose conflicts with standard practice and should be clarified.

    Why the other options are wrong

    • BTaking metformin as usual through the evening before surgery is consistent with standard guidance.
    • CHolding oral agents for 24 hours is a cautious plan that still avoids metformin on the day of surgery.
    • DA smaller evening dose the night before does not carry the risk that a day-of-surgery dose does.

14. Question 14 of 25Medium

    An 82-year-old client who had a left hemispheric stroke 3 days ago is eating lunch while sitting upright in a chair on the stroke unit. The client passed a bedside swallow screen yesterday. Which observation indicates a risk for aspiration?

    1. AA. The client's voice sounds wet and gurgly after swallowing.
    2. BB. The client says the food tastes bland and asks for salt.
    3. CC. The client takes about 30 minutes to finish the meal.
    4. DD. The client holds the cup with the left hand to drink.
    Show answer to question 14

    Answer: A. The client's voice sounds wet and gurgly after swallowing.

    A wet, gurgly voice after swallowing suggests that food or fluid is pooling near the vocal cords or entering the airway, so the meal is stopped and swallowing is reevaluated.

    Why the other options are wrong

    • BAltered taste is common after a stroke and does not indicate unsafe swallowing.
    • CEating slowly is safe and is encouraged after a stroke.
    • DA left hemispheric stroke weakens the right side, so using the left hand is an appropriate adaptation.

15. Question 15 of 25Easy

    A nurse is conducting final preoperative checks for a client scheduled for an inguinal hernia repair. The client has already signed the informed consent document. While being transferred to the surgical stretcher, the client says, 'I feel terrified and I have decided I do not want this operation today.' Which action should the nurse take first?

    1. AA. Inform the client that the consent document is legally binding once signed and placed in the chart.
    2. BB. Review the complications of untreated hernias to help the client reconsider the cancellation.
    3. CC. Reassure the client that pre-surgery anxiety is normal and administer prescribed anxiolytics.
    4. DD. Stop the transfer to surgery immediately and notify the surgeon of the client's decision.
    Show answer to question 15

    Answer: D. Stop the transfer to surgery immediately and notify the surgeon of the client's decision.

    A competent client has the absolute legal and ethical right to withdraw informed consent at any point prior to the procedure, regardless of whether the document was previously signed. The nurse's immediate priority is to halt all transfer procedures and alert the surgeon. Telling the client that a signed form is binding or attempting to convince the client to proceed disregards client autonomy and violates informed consent principles.

16. Question 16 of 25Hard

    A hospitalized client develops oliguria following prolonged intraoperative hypotension. Laboratory analysis shows a urine specific gravity of 1.010, urine sodium of 52 mEq/L, and a fractional excretion of sodium (FeNa) of 2.8%. Which condition do these diagnostic findings most strongly support?

    1. AA. Urinary bladder outlet obstruction
    2. BB. Nephrotic syndrome
    3. CC. Prerenal hypovolemia
    4. DD. Acute tubular necrosis
    Show answer to question 16

    Answer: D. Acute tubular necrosis

    A fractional excretion of sodium (FeNa) greater than 2%, a high urine sodium (>40 mEq/L), and an isosthenuric urine specific gravity (~1.010) reflect intrinsic acute tubular injury where damaged tubular epithelial cells lose the ability to concentrate urine and conserve sodium. In contrast, prerenal hypovolemia features preserved tubular function with avid sodium reabsorption (FeNa < 1%, urine sodium < 20 mEq/L) and concentrated urine (specific gravity > 1.020). Mechanical bladder obstruction or nephrotic syndrome do not typically present with this classic laboratory pattern of acute tubular damage.

17. Question 17 of 25Easy

    A nurse is caring for a client 24 hours after a percutaneous transluminal coronary angioplasty performed via right femoral artery access. The nurse notes expanding erythema measuring 4 cm, localized warmth, induration around the puncture site, and an oral temperature of 101.0 F (38.3 C). Which post-procedural complication is most consistent with these assessment findings?

    1. AA. Femoral pseudoaneurysm
    2. BB. Retroperitoneal hemorrhage
    3. CC. Access-site cellulitis
    4. DD. Arterial thrombosis
    Show answer to question 17

    Answer: C. Access-site cellulitis

    Expanding erythema, localized warmth, induration, and systemic fever at a vascular puncture site are cardinal signs of access-site cellulitis. A pseudoaneurysm presents as a painful, pulsatile mass often accompanied by an audible systolic bruit. Retroperitoneal hemorrhage presents with hemodynamic instability, flank or back pain, and pallor rather than localized superficial erythema.

18. Question 18 of 25Hard

    A client with suspected meningitis underwent a lumbar puncture 30 minutes ago. Which clinical change indicates to the nurse that the client is experiencing the life-threatening complication of brain herniation?

    1. AA. Severe photophobia accompanied by projectile vomiting
    2. BB. Unilateral dilated, nonreactive pupil and irregular respirations
    3. CC. Transient sharp pain radiating down the posterior thigh
    4. DD. Persistent nuchal rigidity with neck flexion causing hip flexion
    Show answer to question 18

    Answer: B. Unilateral dilated, nonreactive pupil and irregular respirations

    Brain herniation occurs when sudden decompression from a lumbar puncture shifts brain tissue downward through the tentorial notch or foramen magnum in the presence of elevated intracranial pressure. Manifestations include an ipsilateral dilated and nonreactive pupil, altered mental status, and Cushing's triad (bradycardia, widening pulse pressure, and irregular respirations). Neck stiffness with hip flexion reflects meningeal irritation characteristic of meningitis itself rather than acute herniation.

19. Question 19 of 25Easy

    The nurse is evaluating a client who reports dizziness and lightheadedness when rising from bed. Which change in vital signs upon standing confirms that the client has orthostatic hypotension?

    1. AA. An increase in heart rate of 12 beats/min with no change in blood pressure
    2. BB. A decrease in systolic blood pressure of 24 mm Hg with an increase in heart rate of 14 beats/min
    3. CC. A decrease in systolic blood pressure of 12 mm Hg with an unchanged heart rate
    4. DD. A decrease in diastolic blood pressure of 6 mm Hg with an increase in heart rate of 8 beats/min
    Show answer to question 19

    Answer: B. A decrease in systolic blood pressure of 24 mm Hg with an increase in heart rate of 14 beats/min

    Orthostatic hypotension is clinically defined as a drop in systolic blood pressure of at least 20 mm Hg, a drop in diastolic blood pressure of at least 10 mm Hg, or both, within 3 minutes of standing. A drop in systolic blood pressure of 24 mm Hg satisfies this diagnostic threshold. A diastolic drop of only 6 mm Hg or a systolic drop of only 12 mm Hg does not meet the established criteria.

20. Question 20 of 25Hard

    A 63-year-old client was admitted to the medical unit 2 days ago with pyelonephritis. At 0400, the client is newly restless and keeps pulling at the gown. Compared with readings 4 hours earlier, the heart rate has risen from 92 to 126/min and the respiratory rate from 18 to 30/min, and the blood pressure has fallen from 128/76 to 92/54 mm Hg. Oxygen saturation is 94% on room air. Which action should the nurse take first?

    1. AA. Recheck the vital signs in 30 minutes to confirm the trend
    2. BB. Collect a urine specimen for culture before the next antibiotic dose
    3. CC. Activate the rapid response team to evaluate the client now
    4. DD. Page the health care provider and wait for the return call
    Show answer to question 20

    Answer: C. Activate the rapid response team to evaluate the client now

    New restlessness, a rising heart and respiratory rate, and a falling blood pressure are signs of early deterioration, here consistent with developing sepsis. These findings meet rapid response criteria, and activating the team brings critical care help to the bedside right away.

    Why the other options are wrong

    • AWaiting 30 minutes delays care for a client who already meets criteria for urgent evaluation.
    • BCultures may be needed, but collecting a specimen does not address the client's worsening perfusion.
    • DWaiting for a return call delays treatment; the rapid response team exists so that nurses can get immediate help.

21. Question 21 of 25Easy

    A nurse is assessing a pediatric client admitted with acute laryngotracheobronchitis (croup). Auscultation over the anterior neck reveals a high-pitched, harsh sound predominantly on inspiration. Which adventitious sound should the nurse document?

    1. AA. Coarse wheezing
    2. BB. Stridor
    3. CC. Fine crackles
    4. DD. Pleural friction rub
    Show answer to question 21

    Answer: B. Stridor

    Stridor is a harsh, high-pitched, predominantly inspiratory sound heard over the trachea and larynx, signaling upper airway obstruction or edema such as that seen in croup. Wheezing represents turbulent airflow through narrowed lower airways and is typically musical and more prominent during expiration. Crackles represent popping open of collapsed small airways and alveoli, while a pleural friction rub is a grating sound caused by inflamed pleura rubbing together.

22. Question 22 of 25Easy

    A nurse reviews the medical records of four postoperative clients. Which client has the highest risk for developing deep vein thrombosis (DVT)?

    1. AA. A 42-year-old client who had an elective laparoscopic cholecystectomy with a BMI of 24 kg/m²
    2. BB. A 28-year-old client who had an open appendectomy and ambulated 4 hours postoperatively
    3. CC. A 50-year-old client with well-controlled asthma who underwent an uncomplicated inguinal hernia repair
    4. DD. A 68-year-old client with obesity who underwent a total hip arthroplasty under general anesthesia
    Show answer to question 22

    Answer: D. A 68-year-old client with obesity who underwent a total hip arthroplasty under general anesthesia

    Major orthopedic surgery of the lower extremity, advanced age, obesity, and prolonged immobility represent significant cumulative risk factors for venous thromboembolism based on Virchow's triad (venous stasis, endothelial injury, and hypercoagulability). Laparoscopic procedures and early ambulation in younger individuals carry a significantly lower risk of venous stasis. While any surgery carries some risk, total hip arthroplasty confers among the highest baseline risks for deep vein thrombosis.

23. Question 23 of 25Hard

    A 57-year-old client is admitted to the medical unit with melena from a duodenal ulcer and is receiving 0.9% sodium chloride at 75 mL/hr. The nurse reviews the vital sign trend. At 0800: blood pressure 128/78 mm Hg, heart rate 84/min. At 1000: blood pressure 124/88 mm Hg, heart rate 98/min. At 1200: blood pressure 120/96 mm Hg, heart rate 112/min. The client is anxious, and the skin is cool. Which explanation for this trend should the nurse consider most likely?

    1. AA. Pain stimulating the sympathetic nervous system
    2. BB. Anxiety about being admitted to the hospital
    3. CC. Ongoing bleeding with compensatory vasoconstriction
    4. DD. Fluid overload from the intravenous infusion
    Show answer to question 23

    Answer: C. Ongoing bleeding with compensatory vasoconstriction

    The systolic pressure is drifting down while the diastolic pressure rises, so the pulse pressure narrows from 50 to 24 mm Hg as the heart rate climbs. With cool skin, this pattern reflects vasoconstriction that is compensating for continued blood loss before hypotension develops.

    Why the other options are wrong

    • APain usually raises both systolic and diastolic pressure and does not explain a falling systolic pressure with cool skin.
    • BAnxiety can raise the heart rate, but a steadily narrowing pulse pressure in a client with melena points to blood loss.
    • DFluid overload tends to raise systolic pressure and cause crackles or edema, not a falling systolic pressure.

24. Question 24 of 25Hard

    A client with severe malnutrition and cirrhosis takes oral phenytoin 300 mg daily for focal seizures. The total serum phenytoin level is 14 mcg/mL (reference range: 10 to 20 mcg/mL), and the serum albumin level is 2.0 g/dL (reference range: 3.5 to 5.0 g/dL). The client exhibits horizontal nystagmus, dysarthria, and an unsteady gait. Which interpretation by the nurse is correct?

    1. AA. The client is experiencing toxicity because low albumin increases the active free drug level.
    2. BB. The client's neurological signs are expected manifestations of end-stage liver disease.
    3. CC. The client has a subtherapeutic concentration and requires a dosage increase to control seizures.
    4. DD. The laboratory result is an inaccurate false-positive due to elevated serum bilirubin.
    Show answer to question 24

    Answer: A. The client is experiencing toxicity because low albumin increases the active free drug level.

    Phenytoin is approximately 90% protein-bound under normal physiological conditions; severe hypoalbuminemia leaves a greater proportion of the drug unbound and pharmacologically active despite a total serum concentration within the normal reference range. Attributing the client's nystagmus and ataxia solely to hepatic encephalopathy is dangerous because it overlooks acute phenytoin neurotoxicity requiring dosage reduction. The reported total level accurately reflects total circulating molecules but underestimates biological activity in the setting of low albumin.

25. Question 25 of 25Hard

    An adult client who had an open abdominal aortic aneurysm repair 4 hours ago has a central venous hemoglobin level reported as 6.4 g/dL (64 g/L). Vital signs are: blood pressure 82/46 mm Hg, heart rate 128 beats/min, and urine output 12 mL/hr. After calling the rapid response team and the surgeon to report the critical value, which prescription should the nurse anticipate first?

    1. AA. Intramuscular injection of phytonadione (vitamin K)
    2. BB. Intravenous infusion of regular insulin with 50% dextrose
    3. CC. Emergency transfusion of uncrossmatched packed red blood cells
    4. DD. Oral administration of high-dose ferrous sulfate tablets
    Show answer to question 25

    Answer: C. Emergency transfusion of uncrossmatched packed red blood cells

    A hemoglobin level of 6.4 g/dL accompanied by hypotension, tachycardia, and oliguria in a postoperative vascular surgery client indicates severe hemorrhagic shock, representing a critical, life-threatening emergency that demands immediate blood product resuscitation. Oral iron replacement is completely ineffective for acute, life-threatening hemorrhagic shock. Insulin and dextrose are used to manage severe hyperkalemia, not acute hypovolemic shock from surgical hemorrhage.

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