Question 1

Parents of a child with Kawasaki disease should be taught the importance of keeping follow-up appointments to monitor and prevent which complication?

Accepted Answer

Answer reason: Follow-up is essential to monitor coronary status (e.g., echocardiography) and guide antiplatelet/anticoagulation management to reduce ischemic events. The most serious long-term complication is myocardial ischemia leading to infarction, even in children, due to aneurysm-related clot formation or stenosis. Neurologic infection (encephalitis), renal inflammation (glomerulonephritis), and primary platelet-destruction disorders are not the hallmark preventable sequelae emphasized in Kawasaki surveillance.

Question 2

Which intervention should a nurse expect to use to prevent venous stasis after skeletal traction application?

Accepted Answer

Answer reason: Mechanical prophylaxis promotes venous return by providing graduated external pressure and intermittent calf-muscle pump simulation, directly addressing the mechanism of stasis. Bed rest without prophylaxis worsens stasis risk, and a foam mattress primarily targets pressure-injury prevention rather than venous thromboembolism. Pulmonary care is important for preventing atelectasis but does not prevent lower-extremity venous stasis.

Question 3

Which intervention by the parents is appropriate to “allergy proof” the home?

Accepted Answer

Answer reason: Allergen reduction focuses on minimizing reservoirs for dust mites and other indoor allergens that can trigger respiratory symptoms. Synthetic bedding and foam pillows are less likely to harbor dust mites than traditional materials like feather/down and are easier to keep allergen-controlled with regular cleaning. Carpeting and basements tend to trap dust, mold, and moisture, increasing allergen exposure. Cleaning only twice a month is typically insufficient for significant dust-mite and dust control in sensitized children.

Question 4

The nurse is caring for the client who received conscious sedation during a surgical procedure. Which assessment is most important postoperatively?

Accepted Answer

Answer reason: Assessing respiratory rate and depth directly identifies inadequate ventilation before hypoxemia or hypercapnia becomes severe. Lung sounds may be normal despite dangerous hypoventilation, so they are less sensitive for immediate sedation-related respiratory compromise. Urine output and swallowing ability are important later, but they do not address the most time-critical risk of respiratory depression after sedation.

Question 5

The nurse is caring for a laboring client who developed hypertension of pregnancy. The nurse is concerned when the client displays which finding?

Accepted Answer

Answer reason: Worsening oliguria is a danger sign suggesting progression to severe disease and increased risk for acute kidney injury and other maternal complications. In contrast, decreasing blood pressure and decreasing edema are not typical indicators of deterioration and may reflect improvement or normal variation. Trace proteinuria alone is less concerning than declining urine output because severity is driven more by end-organ dysfunction than by minimal protein levels.

Question 6

The nurse is caring for a client who is receiving intravenous conscious sedation. Which is the nurse’s priority?

Accepted Answer

Answer reason: IV conscious sedation can rapidly depress the central nervous system and compromise airway reflexes, ventilation, and hemodynamic stability, so the earliest and most sensitive indicator of oversedation is a declining LOC. Frequent LOC assessment helps detect progression from intended moderate sedation toward deep sedation, prompting immediate airway support and reversal measures if needed. Urine output, edema, and temperature do not provide timely warning of respiratory depression and are not the primary safety threat during sedation. Prioritizing neurologic responsiveness aligns with ABCs because it signals impending loss of airway protection.

Question 7

A client diagnosed with end-stage liver disease notices a decrease in ascites. The nurse should expect which finding to accompany the decrease in ascites?

Accepted Answer

Answer reason: A decrease in ascites reflects a reduction in excess fluid within the peritoneal cavity, most commonly due to improved fluid mobilization from effective diuresis or fluid management. As third-spaced fluid shifts back into the intravascular space, the kidneys can excrete more water and sodium, leading to increased urine output. Findings like shiny abdominal skin and shallow respirations are associated with worsening, tense ascites that stretches the abdomen and restricts diaphragmatic excursion. Increased ankle edema is not the expected accompanying finding when overall fluid overload/third spacing is improving.

Question 8

The nurse cares for a client with a chest tube. Which symptom would indicate to the nurse the presence of subcutaneous emphysema?

Accepted Answer

Answer reason: Subcutaneous emphysema occurs when air leaks into subcutaneous tissue, producing palpable crepitus that feels like crackling or “rice crispies” under the skin. In a client with a chest tube, this finding suggests an air leak or improper tube/system function allowing air to track into tissues near the insertion site. Dyspnea/shortness of breath and tachycardia are nonspecific responses to many respiratory or pain-related problems and do not uniquely identify air in the subcutaneous tissue. The hallmark assessment cue is crepitus on palpation around the chest tube site and adjacent chest/neck.

Question 9

The nurse assesses a client who is in an arm cast for compartment syndrome. Which is a late symptom of compartment syndrome?

Accepted Answer

Answer reason: Compartment syndrome causes rising intracompartmental pressure that progressively compromises tissue perfusion and nerve/muscle function. Motor weakness progressing to paralysis is a late finding because it reflects significant ischemia and neurologic compromise after earlier sensory changes and escalating pain. Swelling and skin color changes can occur earlier and are less specific for advanced neurovascular compromise. A sudden decrease in pain is not reassuring and may reflect nerve infarction, but loss of motor function is the clearer late manifestation to act on urgently.

Question 10

A client underwent a cholecystectomy and is now complaining of cramping and pain in the left calf. Which action is the nurse’s first priority?

Accepted Answer

Answer reason: Unilateral calf cramping/pain in a post-op client is a red-flag for deep vein thrombosis, which can embolize and become life-threatening. The priority is rapid escalation so the provider can promptly order diagnostic testing (e.g., venous duplex) and initiate anticoagulation or other management as appropriate. Assessing for Homan’s sign is not a reliable or recommended DVT assessment and can be unsafe if it dislodges a clot. Interventions like leg elevation or analgesics may reduce symptoms but do not address the urgent risk of pulmonary embolism and can delay definitive evaluation and treatment.

Question 11

The nurse cares for a client who returns from gastric resection surgery. Which nursing intervention is a priority?

Accepted Answer

Answer reason: Immediate postoperative nursing priorities follow ABCs and prevention/early detection of life-threatening complications. After gastric resection, hemorrhage can occur from the surgical site and may present with tachycardia, hypotension, decreasing urine output, pallor, restlessness, and increasing abdominal drain output or bloody emesis. Early recognition allows rapid intervention (notify provider, labs, fluid/blood resuscitation) before shock develops. Tube management and return of bowel function are important but are not as immediately fatal as uncontrolled bleeding in the immediate post-op period.

Question 12

The nurse cares for a client who underwent abdominal surgery 2 days ago. Which symptom suggests the client has developed complications?

Accepted Answer

Answer reason: New or worsening abdominal distension 48 hours after abdominal surgery can indicate a postoperative complication such as ileus or bowel obstruction with impaired passage of gas and stool. This finding suggests decreased GI motility and possible accumulation of gas/fluids, which requires prompt assessment (bowel sounds, nausea/vomiting, pain pattern) and possible provider notification. In contrast, expected postoperative findings at 2 days often include incisional pain and generalized muscle soreness from positioning and anesthesia effects. Small amounts of serous drainage can be normal early in healing if there are no signs of infection or dehiscence.

Question 13

The nurse cares for a client with end-stage liver disease due to cirrhosis secondary to alcohol abuse. The nurse monitors the client for which potentially life-threatening complication of cirrhosis?

Accepted Answer

Answer reason: Portal hypertension from cirrhosis diverts blood into fragile collateral veins in the esophagus, creating varices that can bleed catastrophically. Variceal rupture can cause rapid, massive upper GI hemorrhage with hematemesis, shock, and death without immediate intervention. Ascites is common but typically develops more gradually and is not immediately fatal unless complicated by infection or respiratory compromise. Epistaxis reflects coagulopathy but is usually less severe than a variceal bleed in terms of immediate mortality risk.

Question 14

A client completes a course of chemotherapy. During this time of nadir, which assessment finding may the nurse encounter?

Accepted Answer

Answer reason: Chemotherapy suppresses bone marrow, and the nadir is the predictable period when blood cell counts are at their lowest, creating the highest infection risk. Neutrophils typically fall most prominently, so the key assessment/lab finding is neutropenia reflected by a reduced ANC. Elevated platelets would be inconsistent with marrow suppression, since thrombocytopenia is more typical during nadir. Electrolyte abnormalities or creatinine elevation can occur with certain agents or dehydration, but they are not the defining, expected nadir finding compared with ANC decline.

Question 15

The nurse cares for a client who is status post right above-knee amputation. The client complains of severe pain below the level of the amputation. The nurse realizes that the client is experiencing?

Accepted Answer

Answer reason: Pain perceived in an amputated limb occurs because the brain and spinal cord can continue to generate pain signals from disrupted peripheral nerves and persistent cortical representation of the missing extremity. Reporting severe pain “below the level of the amputation” is classic for this phenomenon and is a recognized postoperative complication after limb loss. Narcotic withdrawal would be expected to present with autonomic and GI symptoms (e.g., diaphoresis, yawning, abdominal cramping) rather than localized limb pain. Hallucinations and denial are psychosocial/perceptual responses and do not best explain focal pain sensations in a limb that is no longer present.

Question 16

A client experiences a transient ischemic attack (TIA). The nurse informs the client upon discharge that which factor is associated with an increased risk of stroke after a TIA?

Accepted Answer

Answer reason: A TIA is a warning event that indicates unstable cerebrovascular disease and a high short-term risk of ischemic stroke, especially when vascular risk factors are present. Diabetes accelerates atherosclerosis and causes endothelial dysfunction, increasing thrombotic risk and the likelihood of recurrent cerebral ischemia after a TIA. In common risk tools (e.g., ABCD2), diabetes is a specific factor that increases estimated early stroke risk. By contrast, younger age and very brief symptoms generally correlate with lower risk, and “clear speech” is not a risk factor.

Question 17

Which treatment is appropriate for a client with cervical polyps who has been treated with cryosurgery?

Accepted Answer

Answer reason: A topical intravaginal antimicrobial can reduce bacterial load in the vagina/cervix region and help prevent post-procedure infection when prescribed. Douching and tampon use increase infection risk and can interfere with healing by introducing organisms or causing irritation/trauma. Routine oral antibiotics are not typically indicated unless there are signs of infection or specific risk factors requiring systemic coverage.

Question 18

Which nursing intervention is appropriate for an adult client with chronic renal failure?

Accepted Answer

Answer reason: Daily weights under consistent conditions are the most sensitive bedside indicator of fluid volume changes, which is a major complication risk in chronic renal failure. Impaired renal excretion predisposes the client to fluid retention, hypertension, and pulmonary edema, so trending weight helps detect worsening volume overload early and guides dialysis/diuretic/fluid restriction decisions. Large fluid intake can exacerbate edema and cardiopulmonary congestion when urine output is limited. High-phosphorus intake is typically restricted in chronic kidney disease due to hyperphosphatemia and renal osteodystrophy risk, and excessive protein loads increase nitrogenous waste.

Question 19

Two hours after submucous resection, a client’s nostrils are packed and a drip pad is anchored under the nose. Which assessment alerts the nurse that the surgical site is bleeding?

Accepted Answer

Answer reason: Repeated swallowing is a classic early sign that blood is trickling down the throat, indicating ongoing bleeding despite a drip pad. Dry mucous membranes more strongly suggests dehydration or mouth breathing, not acute hemorrhage. Decreased urine output is a later, nonspecific sign of hypovolemia and would not be the earliest assessment cue two hours after surgery.

Question 20

Two hours after starting total enteral nutrition (TEN) through a nasogastric tube, a client starts to have abdominal distention. Which action should the nurse take first?

Accepted Answer

Answer reason: Abdominal distention shortly after initiating enteral nutrition suggests feeding intolerance and possible delayed gastric emptying with rising aspiration risk. The priority first action is to immediately halt the infusion to prevent further gastric overfilling and reduce risk of regurgitation/aspiration while the cause is assessed. After stopping, the nurse would typically assess bowel sounds, abdominal girth/pain, check gastric residual per policy, verify tube placement, and notify the provider if intolerance persists. Aspirating stomach contents may be part of the follow-up assessment, but continuing the feeding during assessment is unsafe. Placing the client supine increases aspiration risk and is inappropriate.

Question 21

A nurse is assessing a 13-year-old child 12 hours after surgery for a compound-fracture repair of the right arm. Which finding requires immediate attention?

Accepted Answer

Answer reason: Pallor indicates decreased oxygenated blood flow to distal tissues and is a late, concerning sign when paired with other “6 P” findings, making it urgent. By contrast, edema and bruising can be expected after fracture repair and immobilization, and capillary refill of about 3 seconds can be borderline but is less specific than visible pallor for ischemia. Immediate action is needed to prevent irreversible tissue injury, including rapid reassessment of pulses/sensation/movement and prompt provider notification if perfusion is threatened.

Question 22

After undergoing a thyroidectomy, a client develops a positive Trousseau’s sign and muscle hyperexcitability, which can lead to tetany. These signs are caused by which of the following?

Accepted Answer

Answer reason: Low ionized calcium increases neuromuscular excitability, producing classic hypocalcemia findings such as Trousseau’s sign and tetany. Potassium abnormalities more commonly cause cardiac conduction changes and generalized weakness rather than carpopedal spasm from neuromuscular irritability. Recognizing this complication is critical because worsening hypocalcemia can also precipitate laryngospasm and seizures, requiring prompt calcium replacement and monitoring.

Question 23

A 32-year-old client has an elevated temperature and decreased hematocrit when she returns for a follow-up visit after having a vaginal hysterectomy. The nurse is aware that the client may be experiencing which of the following?

Accepted Answer

Answer reason: A decreased hematocrit after hysterectomy is a key clue for internal bleeding rather than isolated infection. Infection can cause fever, but it typically does not directly lower hematocrit unless there is significant blood loss or hemolysis, which is less likely in this context. Thromboembolism is more classically associated with dyspnea, chest pain, tachycardia, and hypoxemia rather than a primary drop in hematocrit.

Question 24

A nursing diagnosis addressing risk for impaired tissue integrity would be most appropriate for which client?

Accepted Answer

Answer reason: Vaginal packing can cause pressure necrosis or mucosal trauma if overly tight, left in too long, or if bleeding/edema increases pressure. This makes monitoring for drainage, odor, pain, fever, and timely removal a key nursing priority consistent with preventing impaired tissue integrity. By contrast, endometriosis and oral contraceptive use do not inherently create a direct, ongoing mechanical risk to tissue surfaces requiring integrity-focused precautions.

Question 25

Before a renal biopsy, which information is most important to tell the physician?

Accepted Answer

Answer reason: A renal biopsy carries a significant risk of bleeding because the kidney is highly vascular and the procedure can cause intrarenal hemorrhage. Aspirin and many NSAIDs impair platelet aggregation and can prolong bleeding time, increasing the likelihood of post-biopsy hematoma and hematuria, so the provider may need to hold these agents and/or check coagulation studies before proceeding. In contrast, consent and understanding are important but do not change immediate physiologic risk if an antiplatelet medication is on board. Normal urinary elimination is not the key pre-procedure safety issue compared with anticoagulant/antiplatelet exposure that directly elevates complication risk.

Question 26

A client has recently had a skin graft. What is the most important instruction for the nurse to give the client?

Accepted Answer

Answer reason: Recently grafted skin is fragile and has altered pigmentation and reduced protective melanin, making it highly susceptible to UV injury and hyperpigmentation. Sun exposure can delay healing, worsen scarring, and permanently discolor the grafted area, so strict protection is a high-priority prevention measure. Other instructions like moisturizing or activity guidance are supportive but are secondary to preventing tissue damage during the vulnerable healing phase. A common error is focusing on cosmetic appearance or routine skin care while overlooking UV protection that directly reduces complications.

Question 27

The nurse is monitoring clients for development of a brain abscess. Which client would be the nurse’s lowest priority for monitoring for a brain abscess?

Accepted Answer

Answer reason: Endocarditis can shower septic emboli to the brain, making abscess monitoring important. Meningitis can extend to parenchymal infection and abscess formation, also warranting close surveillance. A liver transplant recipient is immunosuppressed and therefore at higher risk for opportunistic CNS infections, including abscess. Idiopathic epilepsy alone is not an infectious source or immunocompromising condition, so it is the lowest priority for abscess monitoring.

Question 28

The nurse is caring for four clients. Which client requires further nursing assessment due to risk of prerenal failure?

Accepted Answer

Answer reason: Congestive heart failure can markedly reduce forward flow and renal blood flow, placing the client at high risk for prerenal azotemia and progression to ischemic kidney injury if not recognized early. This client warrants focused assessment of perfusion (blood pressure, heart rate), volume status, urine output trends, and renal labs to detect falling GFR early. In contrast, renal calculi more classically cause postrenal obstruction, not prerenal hypoperfusion. A transfusion reaction can cause renal injury, but it is typically intrarenal (hemolysis/pigment nephropathy) rather than prerenal.

Question 29

The nurse is caring for the child with renal insufficiency from impaired blood flow to the kidneys sustained during an MVA. Which assessment finding related to renal insufficiency should be reported immediately to the HCP?

Accepted Answer

Answer reason: In prerenal renal insufficiency from impaired blood flow, prompt reporting is critical because timely interventions (restoring perfusion, evaluating for shock/ongoing bleeding, adjusting fluids/meds) can prevent irreversible tubular damage. This finding also helps detect impending complications such as hyperkalemia, uremia, and volume overload. In contrast, dysuria, frequency, and urgency more strongly suggest lower urinary tract irritation/infection and are typically less immediately life-threatening in the context of renal hypoperfusion.

Question 30

The child who had a tonsillectomy and adenoidectomy (T&A) is brought to the postoperative recovery room. In which position should the nurse place the child?

Accepted Answer

Answer reason: Placing the child on the side allows saliva and any blood to drain out of the mouth rather than pool in the pharynx, reducing risk of airway obstruction, laryngospasm, and aspiration. Supine positioning increases the likelihood of obstructing the airway and swallowing blood, which can both compromise breathing and mask hemorrhage. Semi- or high-Fowler positions may be used later when fully awake and maintaining the airway, but the immediate PACU priority is drainage and airway patency.

Question 31

The nurse determines that a client is at risk for developing anemia if which of the following predisposing factors is identified?

Accepted Answer

Answer reason: Reduced gastric acid can also impair iron absorption, further increasing anemia risk over time. GERD alone does not typically cause anemia unless complicated by bleeding, which is not stated. A colostomy after colon resection does not directly disrupt iron or B12 absorption sites.

Question 32

A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse would instruct the client to?

Accepted Answer

Answer reason: Thrombocytopenia increases bleeding risk, so epistaxis management must minimize further mucosal trauma and reduce aspiration of blood. Leaning forward helps prevent blood from flowing posteriorly into the pharynx, which decreases swallowing/aspiration and allows more accurate assessment of ongoing bleeding. Continuous firm pressure to the soft part of the nose supports local hemostasis by compressing the bleeding vessels. Lying supine with neck extended promotes posterior drainage and swallowing of blood, and blowing the nose can disrupt clots and worsen bleeding.

Question 33

A client who has undergone a lumbar laminectomy is experiencing frequent voiding of small amounts of urine. The nurse suspects the client may have developed which condition?

Accepted Answer

Answer reason: Small, frequent voids are a classic sign of overflow from bladder distention rather than true increased urine production. This is a common complication after laminectomy, especially with residual anesthesia/opioids and temporary nerve root irritation. Diabetes insipidus would cause large volumes of dilute urine, not small amounts, and DKA is characterized by polyuria with systemic metabolic symptoms rather than a postoperative urinary pattern.

Question 34

The nurse is aware that a client who had a transsphenoidal hypophysectomy should be observed carefully for hemorrhage. The nurse is most concerned when the client displays?

Accepted Answer

Answer reason: After transsphenoidal hypophysectomy, bleeding can track posteriorly into the nasopharynx and be swallowed, making it less obvious than external drainage. Persistent swallowing suggests ongoing postnasal bleeding and is an early clinical indicator of hemorrhage that requires immediate assessment of airway, vital signs, and surgical site/drainage. Ear bleeding is more consistent with basilar skull fracture or ear canal pathology rather than the expected route of postoperative bleeding for this approach. Guaiac-positive stools and hematuria indicate gastrointestinal or urinary bleeding sources and are not the typical early signs of hemorrhage from this specific surgery.

Question 35

A client who was diagnosed with multiple sclerosis (MS) asks the nurse if there are any conditions or activities that may exacerbate MS. What is the best response by the nurse?

Accepted Answer

Answer reason: Urinary retention increases the risk of urinary stasis and urinary tract infection, which can worsen neurologic symptoms such as weakness and fatigue. In contrast, appropriately paced exercise and low-impact activities are generally encouraged to maintain mobility and reduce spasticity, provided overheating is avoided. Pregnancy typically decreases relapse rates during gestation, with increased risk mainly in the early postpartum period rather than during pregnancy itself.

Question 36

Which statement indicates that a client needs additional teaching after cataract surgery?

Accepted Answer

Answer reason: ” Post-cataract surgery teaching prioritizes preventing increased intraocular pressure and protecting the operative eye to reduce risks such as hemorrhage, wound dehiscence, or lens displacement. Returning to strenuous exercise and heavy lifting commonly raises intraocular pressure and increases the chance of complications during the early healing period, so this statement signals misunderstanding. In contrast, avoiding bending over helps minimize pressure increases, and keeping the dropper tip from contacting the eye reduces contamination and infection risk. Dietary avoidance until nausea resolves can be reasonable to reduce vomiting/straining, which can also transiently increase intraocular pressure.

Question 37

A client has been placed on a high level of oxygen. The nurse anticipates that this will cause the client’s lungs to do what?

Accepted Answer

Answer reason: When nitrogen is washed out of the alveoli, alveoli can collapse more readily, decreasing the area available for diffusion. This manifests as reduced functional alveolar surface area rather than improved overall uptake. A common distractor is elevated carbon dioxide, which may occur in specific COPD scenarios via hypoventilation/VQ changes, but the direct lung effect of prolonged high FiO2 is loss of functional alveolar units.

Question 38

The nurse is caring for a client who has just returned to the unit after a lobectomy. During assessment of the client, the nurse is aware that the lobectomy site?

Accepted Answer

Answer reason: After a lobectomy, the thoracic cavity does not stay as a persistent “empty space”; the remaining lung tissue gradually expands and the mediastinum shifts toward the operative side as part of expected postoperative physiologic adaptation. This compensatory expansion helps re-establish negative intrathoracic pressure dynamics and improve ventilation of remaining alveoli. Assuming the space simply fills with serous fluid suggests an abnormal residual space/effusion pattern rather than the expected long-term adjustment. Recognizing this expected change supports appropriate postoperative assessment and helps the nurse distinguish normal adaptation from complications such as hemothorax, persistent air leak, or pleural effusion.

Question 39

Which client is at highest risk for developing a pulmonary embolism?

Accepted Answer

Answer reason: Deep vein thrombosis can then embolize to the pulmonary circulation, causing a pulmonary embolism. Pelvic and femur fractures are especially high risk because they often require surgery, prolonged bedrest, and can directly damage large venous structures. Pregnancy is a hypercoagulable state, but an otherwise healthy, ambulatory pregnant client generally has a lower PE risk than a client with acute major fractures. Ambulatory inflammatory joint disease and type 1 diabetes are not as strong immediate risk factors for PE as major lower-extremity/pelvic fractures with likely immobilization.

Question 40

Which factor may lead to bacterial endocarditis in a child with underlying heart disease?

Accepted Answer

Answer reason: A catheter-associated urinary tract infection is a clear source of bacterial invasion and bloodstream spread, increasing the risk of endocardial infection. A brief viral upper respiratory illness is not a typical bacteremia source, and a short-term peripheral IV for one day without signs of infection is less likely to cause significant bacteremia. Dental work that is pretreated with antibiotics is specifically intended to reduce bacteremia risk in high-risk cardiac patients, making it less likely than an active catheter-related infection source.

Question 41

What is the best position for the nurse to place an infant in following cleft lip and palate repair to irrigate the mouth after feeding?

Accepted Answer

Answer reason: A semi-upright posture promotes drainage of irrigating fluid and secretions out of the mouth rather than toward the airway, and turning the head laterally further facilitates dependent drainage. Flat supine positioning increases the chance that fluid will pool posteriorly and be aspirated. Prone with the head over the bed is unsafe and impractical for an infant and can compromise airway monitoring and postoperative safety.

Question 42

A neonate has been diagnosed with a tracheoesophageal fistula. The nurse is aware that the treatment plan will include which measure?

Accepted Answer

Answer reason: Management focuses on preventing respiratory complications while preparing for surgical repair, and antimicrobial coverage is commonly included when aspiration pneumonitis/pneumonia is a concern. Keeping the infant flat and continuing oral feedings increase aspiration risk, so they are not appropriate. A diagnostic catheter is typically left in place for continuous pouch drainage and to help prevent saliva accumulation/aspiration until repair, rather than being removed.

Question 43

What is the most important intervention for the nurse to implement when caring for a neonate with an omphalocele?

Accepted Answer

Answer reason: The core priority with omphalocele is preventing rupture/trauma to the sac and avoiding complications such as infection and fluid/heat loss. Gentle handling and careful positioning reduce tension on the abdominal wall defect and protect exposed viscera while awaiting surgical management. Keeping the defect “dry” is unsafe because exposed tissues should be protected from desiccation and contamination with appropriate coverings per protocol. Frequent touching increases contamination risk and mechanical injury, making it an inappropriate assessment approach.

Question 44

A nurse is caring for an infant with pyloric stenosis. After feeding the infant, the nurse should place him in which position?

Accepted Answer

Answer reason: Elevating the head and torso decreases reflux and supports airway protection. Positioning slightly on the right side promotes gastric emptying because the pylorus is anatomically dependent on the right, helping move stomach contents toward the duodenum. Supine without elevation increases reflux/aspiration risk, and left-side positioning is less effective for facilitating gastric emptying in this condition.

Question 45

The nurse is caring for an unconscious child with Reye’s syndrome. What is the most appropriate nursing intervention?

Accepted Answer

Answer reason: Gentle flexion of the extremities helps reduce restlessness and extension posturing, supports comfort, and can decrease stimuli that may worsen neurologic stress. Supine positioning is not ideal in an unconscious patient because it increases aspiration risk and does not optimize airway protection, which is a critical complication to prevent. The sheepskin and avoiding lotions are skin-comfort measures and do not address the immediate, high-risk neurologic and airway complications.

Question 46

A parent asks the nurse if it is alright to let his child scratch the chickenpox on his abdomen. The nurse explains that if the child scratches the chickenpox, he may be at risk for developing which condition?

Accepted Answer

Answer reason: The key nursing concern is preventing complications by minimizing excoriation and maintaining skin integrity (e.g., trimmed nails, mittens, antipruritics as ordered). While varicella can have systemic complications like neurologic involvement, scratching specifically increases risk for localized bacterial superinfection. Preventing secondary infection also reduces risk of scarring and more serious invasive soft-tissue infection.

Question 47

Which nursing measure should be implemented for a client with von Willebrand’s disease who’s having epistaxis?

Accepted Answer

Answer reason: Firm, continuous compression of the soft part of the nose helps tamponade the bleeding vessels and is the first-line nursing intervention. Positioning supine increases the risk of swallowing blood and aspiration and does not control the bleed. Nasal packing can be traumatic and may worsen bleeding in a bleeding disorder, but it is not the immediate primary measure compared with direct pressure.

Question 48

A 4-year-old child is admitted to the burn unit with a circumferential burn to the left forearm. Which finding should be reported to the physician?

Accepted Answer

Answer reason: New distal sensory changes are an early neurovascular compromise sign and require urgent provider evaluation for interventions such as escharotomy. Normal pulses and brisk capillary refill are reassuring findings and do not indicate worsening perfusion. Preserved ROM with minimal pain is not an alarm finding in this context; the priority is detecting threatened tissue viability and neurologic function distal to the burn.

Question 49

The nurse assesses a client with a cast following a fracture of the radius and is most concerned about which finding?

Accepted Answer

Answer reason: Localized pain over a pressure point under a cast suggests cast-related pressure, impaired tissue perfusion, and risk for skin breakdown or evolving compartment syndrome if unrelieved. This finding is more concerning than expected post-fracture discomfort because it indicates the cast may be too tight or causing focal compression that can progress to neurovascular compromise. Warm, pink fingers and decreased swelling with elevation are reassuring indicators of adequate circulation and effective edema control. The priority is early identification of complications so the cast can be assessed and potentially bivalved or adjusted to prevent ischemia and ulceration.

Question 50

Which nursing intervention should be taken if, while a cast is drying, the client complains of heat from the cast?

Accepted Answer

Answer reason: Heat is expected as plaster or fiberglass casts set because the curing reaction is exothermic and can feel warm to the client. The appropriate nursing action is reassurance and education while continuing routine monitoring for neurovascular compromise and skin integrity. Immediate removal or notifying the provider is not indicated for typical warmth alone and would be an unsafe overreaction. Infection assessment is not the priority because warmth during drying is a normal process and not, by itself, a sign of infection.

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