Question 1

Which finding is indicative of the presence of an infection in a casted extremity?

Accepted Answer

Answer reason: Localized heat or hot spots under a cast suggest infection. The other findings point to neurovascular compromise (ischemia) or expected swelling, not infection.

Question 2

Which assessment finding indicates a complication of Buck's traction?

Accepted Answer

Answer reason: Buck's traction is skin traction; the key complication is neurovascular compromise. Weak pedal pulses indicate impaired circulation. Pin-site drainage applies to skeletal traction, pain may be expected, and brisk capillary refill is normal.

Question 3

A patient with deep vein thrombosis is at highest risk to develop which condition?

Accepted Answer

Answer reason: A thrombus from a DVT can dislodge and travel to the pulmonary arteries, causing a pulmonary embolism. The other options are not typical direct complications of DVT.

Question 4

In a 38-week pregnant patient with BP 174/112 mmHg and 2+ proteinuria undergoing induction of labor, what is the primary complication to prevent by lowering her blood pressure?

Accepted Answer

Answer reason: Severe-range hypertension in preeclampsia primarily threatens maternal intracranial hemorrhage (stroke). Acute BP reduction is done to prevent stroke; magnesium sulfate is used to prevent seizures.

Question 5

A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this condition?

Accepted Answer

Answer reason: In infective endocarditis, vegetations damage valves; a new or worsening heart murmur signals valvular involvement and complications such as regurgitation or embolic sequelae.

Question 6

The nurse is caring for a client with a deep vein thrombosis. Which of the following symptoms would require the nurse's IMMEDIATE attention?

Accepted Answer

Answer reason: Clients with DVT are at high risk for pulmonary embolism; tachypnea (RR 32) is an early sign of PE and demands immediate attention.

Question 7

The nurse is caring for a client with a myocardial infarction. Which of the following assessment findings requires the nurse's IMMEDIATE action?

Accepted Answer

Answer reason: Near-syncope/dizziness in an MI patient suggests dysrhythmias causing decreased cerebral perfusion (e.g., VT or periods of asystole) and requires immediate intervention. Other findings are concerning but less acutely life-threatening.

Question 8

A client with COPD is receiving oxygen per nasal cannula at 2 liters per minute. Which of the following assessments should receive the nurse's IMMEDIATE attention?

Accepted Answer

Answer reason: In COPD, supplemental oxygen can depress hypoxic drive and increase CO2 retention, leading to respiratory acidosis. Rapid shallow respirations signal acute decompensation and require immediate intervention. An SpO2 of 92% may be acceptable for COPD; crackles and thirst are less emergent.

Question 9

Which of the following postpartal clients is at greatest risk for hemorrhage?

Accepted Answer

Answer reason: Cesarean delivery and multiparity increase the risk of postpartum hemorrhage due to uterine atony and surgical blood loss. The other options do not present significant PPH risk factors.

Question 10

The nurse is assessing a client following the removal of a pituitary tumor. The nurse notes that the urinary output has increased and that the urine is very dilute. The nurse should give priority to?

Accepted Answer

Answer reason: Post–pituitary surgery polyuria with very dilute urine indicates diabetes insipidus from lack of ADH. This is a serious postoperative complication requiring prompt provider notification for orders (labs, fluid replacement, desmopressin). Simply documenting or changing IV rate is inappropriate; vasopressors require a prescription.

Question 11

Vaginal examination is contraindicated in pregnancy in which situation?

Accepted Answer

Answer reason: Digital vaginal examination is contraindicated with placenta previa because it can disrupt the placenta and precipitate severe hemorrhage. The other options are not absolute contraindications.

Question 12

Which finding after a colonoscopy requires immediate nursing intervention?

Accepted Answer

Answer reason: Post-colonoscopy abdominal distension and rigidity suggest possible perforation/peritonitis and require immediate evaluation. Mild cramping, flatus, and drowsiness are expected findings after the procedure and sedation.

Question 13

A patient with a tracheostomy is at risk for which priority complication?

Accepted Answer

Answer reason: Tracheostomy alters normal airway protection and swallowing, increasing risk for aspiration; the other options are not primary complications of a tracheostomy.

Question 14

A client with partial thickness burns to the neck, face, and anterior trunk is most at risk for developing which condition?

Accepted Answer

Answer reason: Facial and neck burns indicate potential inhalation injury with rapid airway swelling; laryngeal edema is the most immediate life-threatening risk. Hypovolemia and oliguria can occur, but airway compromise takes priority. Hypernatremia is not expected early.

Question 15

A client with a fractured pelvis from a motor vehicle crash should be closely assessed for which early posttrauma complication?

Accepted Answer

Answer reason: Pelvic fractures commonly cause injury to the bladder or urethra due to proximity, leading to blood in the urine as an early sign. Fever and bradycardia are not expected early posttrauma complications, and pain is expected but not a complication to detect.

Question 16

Why are laxatives not given to patients with possible appendicitis?

Accepted Answer

Answer reason: Laxatives increase intestinal motility and pressure, which can precipitate perforation of an inflamed appendix; therefore they are contraindicated in suspected appendicitis.

Question 17

What is the most important complication of peritoneal dialysis?

Accepted Answer

Answer reason: Peritonitis is the most serious and common complication of peritoneal dialysis due to risk of intraperitoneal infection from the catheter.

Question 18

The nurse is assessing a client hospitalized with duodenal ulcer. Which finding should be reported to the doctor immediately?

Accepted Answer

Answer reason: Hypotension with tachycardia indicates possible acute hemorrhage and shock from GI bleeding in a duodenal ulcer and requires immediate provider notification.

Question 19

A healthcare worker is referred to the nursing office with a suspected latex allergy. The first symptom of latex allergy is usually?

Accepted Answer

Answer reason: Latex allergy commonly first presents as contact urticaria from glove exposure—itching and swelling of the hands. Eye/mouth swelling and dyspnea reflect more severe systemic reactions, and oral itching with bananas is a cross-reactivity sign, not typically the initial presentation.

Question 20

When caring for a client with an anterior cervical discectomy, the nurse should give priority to assessing for post-operative bleeding. The nurse should pay particular attention to?

Accepted Answer

Answer reason: After anterior cervical surgery, hemorrhage can accumulate posteriorly when the client is supine, creating a neck hematoma that can quickly obstruct the airway. Posterior neck swelling is a priority sign of postoperative bleeding and airway compromise, more critical than dressing drainage, pain, or oral bleeding.

Question 21

During morning assessments, the nurse finds that a client's nephrostomy tube has been clamped. The nurse's first action should be to?

Accepted Answer

Answer reason: A clamped nephrostomy tube obstructs urinary drainage and can quickly damage the kidney; the priority is to restore flow by unclamping. Irrigation requires an order and assessing the bag or bladder does not address the immediate obstruction.

Question 22

The school nurse is assessing an elementary student with hemophilia who fell during recess. Which symptoms indicate hemarthrosis?

Accepted Answer

Answer reason: Hemarthrosis (joint bleeding) typically presents with warmth, redness, swelling/pain, and reduced range of motion. Coolness/blue discoloration suggests poor perfusion, and tingling without ROM loss is less characteristic.

Question 23

The nurse is assessing a 6-year-old following a tonsillectomy. Which one of the following signs is an early indication of hemorrhage?

Accepted Answer

Answer reason: Bright red blood from the mouth indicates active postoperative bleeding after tonsillectomy. HR of 90 is normal for a 6-year-old; dark brown emesis suggests old blood; early sign would be frequent—not infrequent—swallowing during sleep.

Question 24

The nurse is evaluating the intake and output of a client for the first 12 hours following an abdominal cholecystectomy. Which finding should be reported to the physician?

Accepted Answer

Answer reason: Urine output should be ≥30 mL/hr in adults; 285 mL over 12 hours (~24 mL/hr) indicates oliguria and potential hypovolemia/renal hypoperfusion and should be reported. The other findings are expected early post-op.

Question 25

The nurse is assessing a client with a closed reduction of a fractured femur. Which finding should the nurse report to the physician?

Accepted Answer

Answer reason: After a long-bone fracture, chest pain and dyspnea suggest a fat or pulmonary embolism, an acute complication requiring immediate provider notification. The other findings are expected or mild.

Question 26

The nurse is preparing a client for discharge following the removal of a cataract. The nurse should tell the client to?

Accepted Answer

Answer reason: After cataract surgery the client should avoid activities that increase intraocular pressure, such as bending at the waist. Aspirin increases bleeding risk, the eye shield is worn during sleep, and showering must be modified to keep water out of the eye.

Question 27

The nurse is caring for a client following a Whipple procedure. The nurse notes that the drainage from the nasogastric tube is bile tinged in appearance and has increased in the past hour. The nurse should?

Accepted Answer

Answer reason: After a Whipple, increasing bile-tinged NG output can indicate disruption/leak of the biliary or pancreatic anastomosis and is an abnormal postoperative finding requiring prompt provider notification. The NG tube should not be irrigated or adjusted without an order.

Question 28

The nurse is caring for a client following a transphenoidal hypophysectomy. Post-operatively, the nurse should?

Accepted Answer

Answer reason: After transphenoidal hypophysectomy, priority is monitoring for cerebrospinal fluid leak; a halo sign on the nasal dressing suggests CSF. Toothbrushing and forceful coughing increase intracranial pressure and disrupt the incision, and ambulation is not the priority risk-focused action.

Question 29

Clients with sickle cell anemia are taught to avoid activities that cause hypoxia and hypoxemia. Which of the following activities would the nurse recommend?

Accepted Answer

Answer reason: Sickle cell clients should avoid hypoxic stressors such as high altitude, cold exposure, and air travel that can reduce oxygenation. A ground-level bus trip to a museum does not impose hypoxia or cold stress, unlike the mountains, skiing, or airplane travel.

Question 30

Which of the following would be the priority nursing diagnosis for the adult client with acute leukemia?

Accepted Answer

Answer reason: Thrombocytopenia in acute leukemia places the client at high risk for bleeding, a potentially life-threatening complication; this risk takes priority over discomfort, fatigue, or family process issues.

Question 31

The home health nurse is visiting a client with autoimmune thrombocytopenic purpura (ATP). The client's platelet count currently is 80,000. It will be most important to teach the client and family about?

Accepted Answer

Answer reason: Platelets of 80,000 indicate thrombocytopenia with increased risk for bleeding; priority teaching is bleeding precautions (soft toothbrush, avoid NSAIDs/trauma, notify provider for bleeding). Other options are less directly targeted.

Question 32

The client has surgery for removal of a Prolactinoma. Which of the following interventions would be appropriate for this client?

Accepted Answer

Answer reason: After transsphenoidal removal of a pituitary tumor, elevate HOB ~30° to reduce intracranial pressure and prevent CSF leak. Avoid Trendelenburg, coughing, and Valsalva, which increase ICP.

Question 33

A client with hemophilia has a nosebleed. Which nursing action is most appropriate to control the bleeding?

Accepted Answer

Answer reason: Direct pressure to the soft lower nose is the most effective immediate measure to control epistaxis. Sitting position and ice can help but do not directly stop bleeding; acetaminophen does not control bleeding.

Question 34

A client has had a unilateral adrenalectomy to remove a tumor. The most important measurement in the immediate post-operative period for the nurse to take is to?

Accepted Answer

Answer reason: Post-adrenalectomy patients are at high risk for hemodynamic instability and hemorrhage, especially after removal of a catecholamine-secreting tumor. The most critical immediate assessment is blood pressure monitoring to detect hypotension/shock early.

Question 35

A client had a total thyroidectomy yesterday. The client is complaining of tingling around the mouth and in the fingers and toes. What would the nurses' next action be?

Accepted Answer

Answer reason: Perioral and distal tingling after thyroidectomy indicates possible hypocalcemia from parathyroid injury. The priority is to check serum calcium and manage accordingly to prevent tetany/airway compromise.

Question 36

The client with AIDS should be taught to?

Accepted Answer

Answer reason: Skin color changes can signal complications such as Kaposi sarcoma lesions, jaundice, or anemia in clients with AIDS and should be reported promptly. Warm climates are not specifically contraindicated, exercise is encouraged as tolerated, and herbals are not universally prohibited (they should be discussed with the provider rather than completely avoided).

Question 37

A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is?

Accepted Answer

Answer reason: Post-tonsillectomy the immediate priority is airway protection; bleeding and edema can lead to aspiration of blood/secretions. Thus preventing injury/aspiration is the top nursing diagnosis over nutrition, communication, or urinary issues.

Question 38

The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a diagnosis of a ruptured ectopic pregnancy?

Accepted Answer

Answer reason: Ruptured ectopic pregnancy classically causes sudden, severe unilateral lower abdominal pain. Painless bleeding suggests placenta previa; cramping is nonspecific; upper quadrant throbbing pain is not typical.

Question 39

The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse should give priority to assessing the?

Accepted Answer

Answer reason: Immediately post-op the priority is early detection of life-threatening complications such as hemorrhage. Assessing the Davol drain for amount and character of output helps identify excessive bleeding. Pain, nutrition, and immobilizer assessment are important but not as critical immediately.

Question 40

The nurse is caring for a client admitted with multiple trauma. Fractures include the pelvis, femur, and ulna. Which finding should be reported to the physician immediately?

Accepted Answer

Answer reason: Pelvic fractures place the urinary tract at high risk for injury; hematuria indicates possible bladder/urethral damage and internal bleeding and requires immediate provider notification. The other symptoms are common but not emergent.

Question 41

A client with an inguinal hernia asks the nurse why he should have surgery when he has had a hernia for years. The nurse understands that surgery is recommended to?

Accepted Answer

Answer reason: Inguinal hernias risk incarceration and strangulation, which can obstruct blood flow and cause bowel necrosis; surgery is recommended primarily to prevent this complication.

Question 42

An elderly client is hospitalized for a transurethral prostatectomy. Which finding should be reported to the doctor immediately?

Accepted Answer

Answer reason: After TURP, bright red urine with numerous clots indicates active bleeding and requires immediate provider notification. An output of 40–50 mL/hr is adequate, some dark/red urine with few clots can be expected early post-op, and regular pain-med requests are expected.

Question 43

Which statement by the parent of a child with sickle cell anemia indicates an understanding of the disease?

Accepted Answer

Answer reason: Dehydration precipitates sickling and vaso-occlusive pain crises; encouraging increased fluids demonstrates correct understanding. Pain is not from too many RBCs, cold/altitude activities like skiing increase risk, and if both parents are carriers each child has a 25% risk—not 'very little.

Question 44

The nurse is caring for an 8-year-old following a routine tonsillectomy. Which finding should be reported immediately?

Accepted Answer

Answer reason: Respiratory stridor indicates airway obstruction post-tonsillectomy and is an emergency requiring immediate reporting. The other findings are common/expected: reluctance to swallow and blood-tinged saliva are typical, and an axillary temperature of 99°F is not concerning.

Question 45

A 2-year-old is hospitalized with a diagnosis of Kawasaki's disease. A severe complication of Kawasaki's disease is?

Accepted Answer

Answer reason: Kawasaki disease can lead to coronary artery aneurysms (including giant aneurysms). Brushfield spots occur in Down syndrome, Hutchinson’s teeth in congenital syphilis, and coxa plana in Legg-Calvé-Perthes disease.

Question 46

A client with a laryngectomy returns from surgery with a nasogastric tube in place. The primary reason for placement of the nasogastric tube is to?

Accepted Answer

Answer reason: After laryngectomy, oral intake is avoided initially to protect the pharyngeal suture line. An NG tube allows nutrition/decompression without oral feeding, thereby minimizing contamination of the suture line and promoting healing.

Question 47

A nurse is caring for a client with a myocardial infarction. The nurse recognizes that the most common complication in the client following a myocardial infarction is?

Accepted Answer

Answer reason: Post-MI myocardial irritability and conduction system ischemia make cardiac dysrhythmias the most common complication; hypertrophy and hyperkalemia are not typical immediate complications.

Question 48

A client develops a temperature of 102°F following coronary artery bypass surgery. The nurse should notify the physician immediately because elevations in temperature?

Accepted Answer

Answer reason: Fever raises metabolic rate and heart rate, increasing cardiac workload and cardiac output—dangerous after CABG. It does not indicate tamponade or graft rejection, and it does not decrease cardiac output.

Question 49

A 4-year-old is admitted with acute leukemia. It will be most important to monitor the child for?

Accepted Answer

Answer reason: Acute leukemia commonly causes anemia and thrombocytopenia, making pallor and bleeding life‑threatening priorities to monitor. Other options are possible findings but are less critical or less immediate.

Question 50

A high school student returns to school following a 3-week absence due to mononucleosis. The school nurse knows it will be important for the client?

Accepted Answer

Answer reason: Mononucleosis often causes splenomegaly; avoiding contact sports for several weeks prevents splenic rupture, a serious complication. The other options are not key or are inappropriate (e.g., antibiotics are not continued long-term).

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