Question 1

The client is being evaluated for possible acute leukemia. Which inquiry is most important?

Accepted Answer

Answer reason: ” Acute leukemia commonly causes bone marrow failure with neutropenia, making recurrent or severe infections a key early and safety-relevant clue. Asking about recent respiratory infections directly screens for impaired immune function and helps identify current or recent infection risk that can rapidly become life-threatening. This information also guides immediate precautions and urgency of evaluation (e.g., fever vigilance, cultures, and early antimicrobial therapy if indicated). Weight loss, sleep changes, and altered alertness can occur in many conditions but are less specific and less immediately tied to the most dangerous complication of suspected leukemia.

Question 2

The nurse is taking vital signs on her patient with a diagnosis of ALL. His temperature is 38.7C. What is the nurse's first priority?

Accepted Answer

Answer reason: The safest first step is to complete a focused assessment (ABCs, mental status, hemodynamics, symptoms, and history) to determine stability and identify red flags that drive urgent actions and escalation. Nonpharmacologic cooling is not the priority and does not address the underlying risk of infection. Starting an IV may be needed soon for labs/antibiotics/fluids, but it should follow rapid assessment and notification based on the patient’s overall condition.

Question 3

The nurse is performing an assessment of a newly admitted patient. Which is an example of subjective data?

Accepted Answer

Answer reason: Subjective data are information the client states that cannot be directly measured or independently verified by the nurse during the assessment. A patient’s report of using an herbal product is obtained through the health history and depends on the patient’s account. In contrast, blood pressure, weight, and laboratory results (CBC) are objective findings that are measurable and observable. Recognizing subjective data is important because it guides follow-up questions, medication reconciliation, and safety screening for interactions and bleeding risk with supplements.

Question 4

The client diagnosed with type 1 diabetes is complaining of being jittery and nervous and has a headache. Which action should the nurse implement first?

Accepted Answer

Answer reason: These symptoms (jittery, nervous, headache) are classic for hypoglycemia, which can rapidly progress to neuroglycopenia and loss of consciousness, so immediate assessment of blood glucose is the priority. Confirming the glucose level guides whether fast-acting carbohydrate is indicated and helps avoid inappropriate treatment (e.g., giving juice if the client is actually hyperglycemic). Asking about last insulin dose is useful but does not address the immediate safety risk. Vital signs are important, but they do not confirm or exclude hypoglycemia and should not delay a targeted glucose check.

Question 5

The nurse cares for a client with type I diabetes mellitus. Which action, by the nurse, best assesses the chronic complication of autonomic neuropathy?

Accepted Answer

Answer reason: Measuring blood pressure in both supine/sitting and standing positions directly screens for this autonomic dysfunction by revealing a position-related drop in pressure. Checking sensation in fingers and toes evaluates peripheral sensory neuropathy (somatic), not autonomic function. Inspecting for ulcers assesses consequences of sensory loss and poor perfusion, which is indirect and not a direct autonomic assessment.

Question 6

The nurse is caring for a COPD patient in the Intensive Care Unit, who is having ABGs drawn every shift. The nurse knows that the sequence for interpreting this test includes the following steps: • Examine the PaO2. • Examine the pH. • Examine the HCO3. • Examine the PaCO2. The best sequence for interpreting the ABG is?

Accepted Answer

Answer reason: Once the direction of the disturbance is known, PaCO2 and HCO3 are then used to decide whether the primary problem is respiratory or metabolic and whether compensation is occurring. Oxygenation (PaO2) is assessed as a separate but important step after the acid–base status is established, especially in COPD where hypoxemia and hypercapnia can coexist. Starting with PaO2 can delay recognition of the primary acid–base disorder and lead to incorrect attribution of abnormalities.

Question 7

The nurse is assessing a patient's abdomen-which examination technique should the nurse use first??

Accepted Answer

Answer reason: The standard sequence for an abdominal examination is Inspection, Auscultation, Percussion, and Palpation. Inspection is the first step because it allows for a visual assessment of the abdomen without altering physical findings. Auscultation is performed before percussion and palpation because physical manipulation of the abdomen can stimulate peristalsis and alter bowel sounds, which would lead to inaccurate clinical findings.

Question 8

A nurse is caring for a school-age child who has nephrotic syndrome. Which of the following is an appropriate action by the nurse?

Accepted Answer

Answer reason: Nephrotic syndrome is characterized by heavy proteinuria, so tracking urinary protein is a key assessment to gauge disease activity and response to therapy. Regular monitoring helps identify worsening glomerular permeability and guides timely adjustments in care (e.g., evaluating edema/volume status and effectiveness of corticosteroids). Encouraging increased oral fluids is not routinely indicated because these children can have significant edema and may require individualized fluid management rather than automatic increases. Eliminating salt entirely is unnecessarily restrictive; the typical intervention is sodium restriction to reduce edema, not total elimination.

Question 9

Peripheral vision is evaluated by the nurse using?

Accepted Answer

Answer reason: This method specifically detects deficits in peripheral vision by having the client identify fingers or movement entering from the periphery while focusing on a central point. The cover test evaluates ocular alignment/strabismus rather than peripheral fields, and the corneal light reflex also assesses alignment. Cardinal fields of gaze testing assesses extraocular muscle function and cranial nerves III, IV, and VI, not peripheral vision.

Question 10

A client states to the nurse, "I am having difficulty seeing." Which cranial nerve will the nurse test first?

Accepted Answer

Answer reason: Visual complaints are assessed first by evaluating the primary sensory pathway for vision. Cranial nerve II (optic) mediates visual acuity and visual fields, making it the most direct initial assessment for “difficulty seeing.” Cranial nerves IV and VI control extraocular movements and are tested when diplopia or gaze limitation is suspected rather than primary loss of vision. Cranial nerve VIII relates to hearing and balance and does not address vision symptoms.

Question 11

A nurse admits a client newly diagnosed with hypertension. What is the best method for assessment of the blood pressure?

Accepted Answer

Answer reason: An inter-arm difference can suggest vascular disease and may change risk stratification and management decisions, so missing it can lead to underestimation of hypertension severity. Position changes (sitting/standing) are reserved for assessing orthostatic hypotension rather than baseline hypertension assessment. Measuring immediately after exercise can falsely elevate readings and does not reflect resting blood pressure needed for diagnosis and follow-up.

Question 12

The nurse is assisting with a vaginal delivery of a full-term infant. Which assessment finding of the newborn is most important for the nurse to follow-up?

Accepted Answer

Answer reason: Cutaneous lumbosacral markers are higher-risk because they may be associated with tethered cord, leading to progressive motor, sensory, and bladder/bowel dysfunction if not identified early. By contrast, a flat bluish area on the buttocks is commonly a benign Mongolian spot, and localized scalp edema is often caput succedaneum that resolves without intervention. A small whitish substance in the axilla is consistent with vernix and routine newborn skin findings.

Question 13

A patient suffering from presbycusis has the most difficulty hearing which of the following sounds?

Accepted Answer

Answer reason: Presbycusis is age-related sensorineural hearing loss that typically affects high-frequency sounds first due to degeneration of cochlear hair cells. High-pitched voices (especially children’s voices) and consonant sounds are therefore hardest to perceive, making speech seem unclear even when volume is adequate. In contrast, a man’s voice and low-frequency environmental sounds like thunder are lower pitch and are generally easier to hear earlier in presbycusis. This pattern is central to assessing hearing complaints and anticipating communication needs in older adults.

Question 14

Following report, which newborn infant should the nursery nurse monitor first?

Accepted Answer

Answer reason: Cyanosis in a newborn can signal inadequate oxygenation and requires immediate assessment to rule out respiratory distress or congenital heart disease. Perioral/circumoral color changes may represent central cyanosis or early hypoxemia, so the nurse should promptly evaluate airway, breathing, oxygen saturation, and perfusion. In contrast, a positive Babinski reflex is an expected primitive reflex in infants, and a negative Ortolani sign is a normal hip-screen finding. Telangiectatic nevi are typically benign skin findings and do not take priority over possible compromised oxygenation.

Question 15

When ICP increases slowly in a TBI patient, what is usually the first symptom/sign noted upon assessment?

Accepted Answer

Answer reason: With a gradual rise in intracranial pressure, the body can initially compensate, so dramatic vital-sign changes are typically delayed. Early assessment findings often reflect developing optic disc swelling from sustained elevated ICP, which may be seen as papilledema (and may correlate with early visual complaints/headache if assessed). Bradycardia is classically part of Cushing’s response and is a later sign of significant ICP elevation with threatened cerebral perfusion. Decerebrate posturing indicates severe brainstem involvement and is also a late, ominous finding; hypotension is not an expected early sign and would worsen cerebral perfusion pressure.

Question 16

A nurse is performing an admission skin assessment on a client. Which finding would prompt further investigation by the nurse?

Accepted Answer

Answer reason: This finding combines two high-risk features (variegated pigmentation and size threshold), so it warrants prompt follow-up such as focused history, dermoscopic evaluation, or referral for biopsy consideration. In contrast, a uniformly light-brown lesion with smooth borders is more consistent with a benign nevus. A tiny (1 mm) round red spot is commonly a benign vascular lesion (e.g., petechia/cherry angioma) unless accompanied by other systemic bleeding or trauma findings.

Question 17

The nurse provides care for a client with suspected scabies. The nurse expects which assessment finding?

Accepted Answer

Answer reason: Scabies is caused by Sarcoptes scabiei mites that burrow into the stratum corneum, producing characteristic serpiginous burrows along with intense pruritus (often worse at night). Linear, wavy, thread-like tracks are the classic assessment clue and reflect the mite’s path under the skin, commonly in interdigital spaces, wrists, and flexural areas. In contrast, thick honey-colored crust points to impetigo rather than scabies, and nonspecific papules can occur with many rashes without identifying the underlying cause. Recognizing burrows is important for timely isolation precautions and treatment of the client and close contacts.

Question 18

The nurse is obtaining a pulse rate for a client with a dysrhythmia. Which of the following actions should the nurse take?

Accepted Answer

Answer reason: Dysrhythmias can produce irregular beats and variable stroke volume, so shorter counting intervals and extrapolation increase measurement error. The apical pulse best reflects actual ventricular contractions heard at the heart and is the preferred site when rhythm is irregular. Counting for a full 60 seconds captures variability and provides the most accurate rate to guide clinical decisions (e.g., medication administration and monitoring for instability). A radial pulse can undercount during dysrhythmia due to a pulse deficit, making it less reliable than a full-minute apical assessment.

Question 19

A 7-month-old infant is admitted to the unit with suspected bacterial meningitis after receiving an initial dose of antibiotics in the emergency department. Frequent assessment of which of the following is most important in the plan of care?

Accepted Answer

Answer reason: In infants, the anterior fontanel provides a sensitive, bedside indicator of increased intracranial pressure (e.g., bulging/tense fontanel) before more advanced signs are obvious. Tracking fontanel changes supports timely escalation (airway protection, urgent provider notification, imaging/ICP management) to prevent herniation and other complications. Pupillary response is also a neuro check, but it is typically a later or less age-specific indicator than fontanel status in a 7-month-old. Babinski is normally present in infants and pulse pressure is less direct for detecting rising intracranial pressure than assessing the fontanel.

Question 20

Client with heart failure has an 8 hr urine output of 200ml. Nurse first action?

Accepted Answer

Answer reason: Lung auscultation helps identify pulmonary congestion (crackles) that would contraindicate simply increasing fluids and supports the need for diuresis/oxygenation interventions. Initiating an IV for diuretics is a treatment step that generally requires an order and should follow focused assessment data. Notifying the provider may be necessary, but after the nurse first gathers key assessment findings to report and to guide urgent management.

Question 21

Which description by a client reporting vertigo would concern you the most?

Accepted Answer

Answer reason: g., brainstem/cerebellar ischemia) is more concerning than peripheral vestibular causes and often occurs without auditory symptoms. Hearing loss and tinnitus more strongly suggest a peripheral inner-ear disorder such as Ménière disease or labyrinthitis, which is typically less immediately life-threatening. Vertigo described as “merry-go-round” and episodic patterns are common in benign peripheral etiologies like BPPV or vestibular neuritis depending on duration and triggers. A report of vertigo without hearing changes should prompt focused neurologic assessment and consideration of urgent evaluation for stroke, especially if any focal deficits are present.

Question 22

The nurse is monitoring a client who is in active labor with a cervical dilation of 6 cm. Which uterine assessment finding requires an intervention by the nurse?

Accepted Answer

Answer reason: In active labor, typical contraction duration is about 45–60 seconds; a duration approaching or exceeding 90 seconds suggests uterine hyperstimulation and warrants nursing action (e.g., repositioning, IV fluids, evaluating oxytocin if infusing, and fetal assessment). A frequency every 3 minutes and an intensity around 45 mm Hg are generally expected patterns in active labor when the fetus tolerates labor. A resting tone near 10 mm Hg is normal and indicates adequate uterine relaxation between contractions.

Question 23

As the shift begins, you are assigned to care for the following patients. Which patient should you assess first?

Accepted Answer

Answer reason: The client with hypothyroidism and a heart rate of 48 beats/min is the priority due to clinically significant bradycardia. Severe hypothyroidism can depress cardiac function, leading to decreased heart rate, reduced cardiac output, and potential progression to life-threatening complications such as myxedema coma. A heart rate of 48 indicates instability that requires immediate assessment. In contrast, a heart rate of 94 in Graves disease is expected (mild tachycardia), a glucose of 137 mg/dL in type 2 diabetes is within an acceptable range, and 1+ dependent edema in Cushing disease is mild and not urgent.

Question 24

The nurse provides care for a client in labor. The client received meperidine 20 minutes ago. The fetal heart rate (FHR) is 106 beats/min. Which action does the nurse take next?

Accepted Answer

Answer reason: A borderline low baseline FHR requires further assessment to determine whether it represents a transient, benign change or fetal compromise related to uteroplacental perfusion. The priority next step is to correlate the tracing with contractions to identify patterns such as early decelerations (head compression) versus late decelerations (uteroplacental insufficiency) and to guide immediate nursing interventions. Meperidine can contribute to decreased fetal variability and neonatal respiratory depression, but it does not by itself explain the relationship of the rate to contractions, so further assessment is needed before escalation. Placing the client supine can worsen aortocaval compression and reduce placental blood flow, and giving more opioid could further depress the fetus. Notifying the provider is appropriate if concerning patterns persist after assessment and initial measures, but assessment comes first.

Question 25

The nurse is caring for a client with neutropenia. To monitor for infection, which action by the nurse is a priority?

Accepted Answer

Answer reason: Trending temperature, heart rate, respiratory rate, and blood pressure helps detect subtle or early sepsis indicators when physical findings may be minimal. This action is broad surveillance that can identify infection from any source promptly and trigger rapid follow-up (focused assessment, cultures, provider notification). Listening to lung sounds can help identify pneumonia but is source-specific and less reliable as an earliest indicator than routine vital-sign monitoring in an immunocompromised client.

Question 26

The nurse is caring for a client diagnosed with pneumonia. When considering the client's safety, when will the nurse plan to take the client for a short walk?

Accepted Answer

Answer reason: Checking oxygen saturation provides an objective baseline and helps determine whether supplemental oxygen, rest, or further assessment is needed prior to walking. Lunch or a nap do not directly address the immediate risk of desaturation with exertion. Using an inhaler may be helpful if bronchospasm is present, but the priority safety check is confirming oxygenation status first and monitoring response to activity.

Question 27

A client visits a wellness clinic for a physical examination. The client confides that he is recovering from a ten year addiction to intravenous drugs. Which assessment finding is indicative of a complication of the addictive behavior?

Accepted Answer

Answer reason: IV drug use increases the risk of infective endocarditis due to repeated introduction of skin flora and contaminants into the bloodstream. Endocarditis commonly presents with new or changed heart murmurs, reflecting valvular involvement and turbulent flow. A murmur heard around the left sternal border (including the 4th intercostal space) can fit tricuspid or other valvular pathology that is classically associated with IV drug use. Diffuse crackles/wheezes are nonspecific for IV drug complications, and generalized lymphadenopathy is more suggestive of systemic infection/malignancy rather than a hallmark complication of injection drug use.

Question 28

When assessing the client that presents with a pressure injury, what description best describes an unstageable pressure injury?

Accepted Answer

Answer reason: This prevents accurate staging until the devitalized tissue is removed and the wound base is visible. The other options describe different entities: deep tissue pressure injury (dark purple), a superficial partial-thickness description, and a stage 4 injury with exposed deeper structures. Therefore the description including full-thickness loss with eschar/slough best matches unstageable.

Question 29

The nurse reading an electrocardiogram (ECG) rhythm strip determines that there are 8 QRS complexes in 30 large squares for a 6-second strip. Which heart rate does the nurse calculate?

Accepted Answer

Answer reason: Heart rate on a 6-second ECG strip is estimated by counting the number of QRS complexes in 6 seconds and multiplying by 10 to convert to beats per minute. With 8 QRS complexes in 6 seconds, the calculation is 8 × 10 = 80 beats/min. The mention of 30 large squares supports that the strip length is 6 seconds at standard paper speed (25 mm/s), confirming the correct method. Other options would require a different QRS count in the same 6-second interval, so they do not match the provided rhythm-strip data.

Question 30

While working at a local food processing plant, a flying object penetrates an employee's right eye. The employee is admitted to an emergency department. After administering pain medication, which question is most important for the nurse to ask?

Accepted Answer

Answer reason:  Baseline assessment is essential to interpret current findings and guide urgent management in eye trauma. Establishing pre-injury visual status helps determine whether any decreased acuity is new and potentially related to globe injury, retinal damage, or optic nerve compromise, which influences escalation and documentation. This information also supports accurate comparison during serial neuro-ocular checks after analgesia and any subsequent procedures. In contrast, workplace compensation and emotional support are important but do not change immediate clinical assessment priorities in a potentially vision-threatening injury.

Question 31

The nurse is performing a physical assessment on a patient with an aortic dissection. Which of the following should the nurse avoid during the physical assessment?

Accepted Answer

Answer reason: Deep abdominal palpation can transmit pressure to the abdominal aorta and provoke extension of the dissection or catastrophic bleeding, so it should be avoided. In contrast, inspection and auscultation are noninvasive assessment techniques that do not meaningfully increase aortic wall stress. Repositioning may be done cautiously as needed, but the priority is to avoid maneuvers that directly compress or strain the aorta.

Question 32

You are caring for a child in burn shock. Which of the following assessments indicates the child is getting adequate fluid resuscitation?

Accepted Answer

Answer reason: Strong, palpable distal pulses indicate improved cardiac output and peripheral circulation, which are key targets during early burn fluid replacement. In contrast, skin turgor is unreliable in major burns due to capillary leak and tissue injury, and localized edema can increase even when perfusion remains inadequate. Neurologic status may improve with perfusion but is less specific and can be confounded by pain, hypoxia, medications, or head injury, making it a weaker indicator than perfusion findings.

Question 33

To obtain accurate continuous blood pressure readings via a radial arterial catheter, the nurse places the air-filled interface of the stopcock at the phlebostatic axis. Where is it located?

Accepted Answer

Answer reason: This standard reference point is the 4th intercostal space at the mid-axillary line, halfway between the anterior and posterior chest (mid-AP diameter), ensuring hydrostatic pressure does not falsely elevate or lower readings. If the transducer is placed too high, the measured pressure will be artifactually low; if too low, it will read artifactually high due to the fluid column effect. The other landmarks listed correspond to cardiac auscultation points (e.g., aortic area, mitral area) rather than the hemodynamic leveling reference used for arterial lines.

Question 34

A client with a hemorrhagic cerebrovascular accident reports a sudden headache, rating the pain 10 on a 0 to 10 scale. Which intervention does the nurse perform first?

Accepted Answer

Answer reason: A sudden, severe headache in a patient with hemorrhagic stroke is a potential sign of worsening intracranial bleeding and rising intracranial pressure, so immediate reassessment is the priority. A focused neuro assessment (LOC, pupils, motor strength, speech, vital signs trends) identifies acute deterioration and establishes a baseline to guide urgent escalation. Calling the rapid response team or notifying the provider may be necessary next, but the nurse should first rapidly assess to determine severity and provide actionable data. Giving acetaminophen does not address the life-threatening neurologic risk and could delay recognition of neurologic decline.

Question 35

A four-year-old patient presents to the Emergency Department (ED) with scrotal swelling. The nurse notes which of the following findings with a hydrocele?

Accepted Answer

Answer reason: A hydrocele is a fluid collection around the testis, so it classically transilluminates when a light is applied. Because it is a closed fluid-filled sac rather than herniated bowel, it is typically not reducible with gentle pressure. This distinguishing combination helps separate hydrocele from an inguinal hernia, which is usually reducible and does not reliably transilluminate. Opacity would suggest solid tissue, blood, or another mass rather than simple serous fluid.

Question 36

The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On assessment of the client, the nurse should expect to note which finding?

Accepted Answer

Answer reason: This reflects delayed feedback in central respiratory control, commonly seen with heart failure, neurologic injury, or during sleep in critically ill patients. The key identifying feature is the predictable rhythm with recurring apneic pauses. In contrast, regular rapid deep sustained breathing suggests Kussmaul respirations, and totally irregular breathing is more consistent with Biot’s (ataxic) respirations.

Question 37

The nurse is evaluating a 52-year-old male for risk factors for coronary artery disease (CAD). The patient is overweight, male, and smokes a pack a day. The nurse questions the patient about other risk factors including?

Accepted Answer

Answer reason: Asking about diabetes directly identifies a high-risk comorbidity that changes screening intensity and prevention targets (e.g., blood pressure and lipid goals). Elevated HDL is generally protective rather than a risk factor, so it would not increase CAD risk. Gout is not considered a primary, standard CAD risk factor compared with diabetes in classic risk assessment.

Question 38

An 80-year-old male client with a history of arteriosclerosis is experiencing severe pain in his left leg that started approximately 20 minutes ago. When performing the admission assessment, the nurse would expect to observe which of the following?

Accepted Answer

Answer reason: Acute onset severe unilateral leg pain in a patient with arteriosclerosis suggests acute arterial occlusion causing sudden decreased perfusion distal to the blockage. The most reliable bedside finding is diminished or absent distal pulses on the affected side, often accompanied by coolness, pallor, and delayed capillary refill. Normal warmth and palpable 2+ pulses would argue against acute arterial compromise. Dependent cyanosis is more typical of chronic peripheral arterial disease changes and would not specifically match a sudden 20-minute onset in one leg.

Question 39

A nurse assesses a hospitalized client after a report of sudden abdominal pain. Which assessment finding does the nurse report to the health care provider immediately?

Accepted Answer

Answer reason: This is a time-critical finding requiring immediate provider notification and escalation of monitoring and preparation for emergent imaging/intervention. In contrast, an absent abdominal bruit can be normal and does not indicate an acute vascular catastrophe. Normal bowel sounds and localized firmness may reflect benign or less urgent gastrointestinal issues unless accompanied by other peritoneal or hemodynamic signs.

Question 40

The nurse helps the health care provider (HCP) perform a focused assessment for a client with congestive heart failure (CHF). What is the proper approach when performing a hepatojugular reflux?

Accepted Answer

Answer reason: The hepatojugular (abdominojugular) reflux assesses right-sided heart ability to accommodate increased venous return by applying sustained, firm pressure to the abdomen. Maintaining the pressure for about 10–30 seconds (a shorter 5–15 second window is still consistent with a sustained maneuver) transiently increases venous return; a pathologic response is a sustained rise in JVP. Simply positioning the client at 45 degrees helps visualize JVP but does not constitute the reflux maneuver itself. Asking the client to hold their breath can distort venous findings (Valsalva) and is not part of the proper technique, and the pressure is applied over the right upper abdomen rather than specifically the left upper quadrant.

Question 41

When assessing the new stoma of a client diagnosed with Crohn's disease. Which of these will alert the healthcare provider that the stoma has retracted?

Accepted Answer

Answer reason: Stoma retraction is a postoperative complication where the stoma pulls back to or below skin level, decreasing protrusion and often making the opening appear smaller and less prominent. A narrowed, flattened appearance is consistent with loss of normal protrusion and can lead to leakage and peristomal skin breakdown, warranting prompt provider notification. A healthy stoma should be pink/red and moist, reflecting adequate perfusion, so that finding is expected rather than concerning. A dry, reddish-purple stoma suggests compromised perfusion/ischemia rather than retraction, which is a different urgent complication.

Question 42

The nurse assesses a client for clinical manifestations of carpal tunnel syndrome. Which instruction does the nurse provide the client when conducting the physical examination?

Accepted Answer

Answer reason: " Carpal tunnel syndrome involves median nerve compression, and provocative maneuvers that increase pressure in the carpal tunnel reproduce paresthesias in the thumb, index, and middle fingers. Placing the dorsum of the hands together with wrists flexed is the Phalen test, which is a standard bedside assessment to elicit symptoms. The other maneuvers do not selectively stress the median nerve at the wrist and are more consistent with unrelated neurologic or coordination testing. A positive response during this maneuver supports the suspected diagnosis and guides further evaluation or management.

Question 43

A 10-month old baby with a fractured right femur is admitted to the pediatric unit. Which action should the nurse take first?

Accepted Answer

Answer reason: Initial nursing priority is rapid assessment to identify immediate threats and complications (ABCs, neurovascular status, bleeding, shock, and additional injuries). With an infant femur fracture, the nurse must promptly check distal circulation, movement, sensation, capillary refill, skin color/temperature, and overall stability before implementing other actions. Pain control is important but should follow an initial assessment to ensure no evolving compromise is missed and to establish a baseline. History taking and social work referral may be indicated (including concern for non-accidental trauma in a non-ambulatory infant) but they are not the first priority over physiologic assessment.

Question 44

A 12 year old is diagnosed with a vaso-occlusive sickle cell crisis is complaining of severe headache. What should be the nurse's initial intervention?

Accepted Answer

Answer reason: In sickle cell vaso-occlusive crisis, a sudden severe headache is a potential neurologic emergency because cerebral vaso-occlusion can cause ischemic stroke. The priority initial nursing action is rapid focused assessment to identify red flags (altered LOC, focal deficits, seizures) and establish a baseline for urgent escalation. Interventions like oxygen, opioids, and IV fluids may be indicated but should not delay assessment when symptoms suggest possible acute CNS complication. Early recognition and prompt notification facilitate timely neuroimaging and disease-specific treatment to prevent permanent deficits.

Question 45

The nurse is monitoring a 3-month-old infant for signs of increased intracranial pressure. On palpation of the fontanels, the nurse notes that the anterior fontanel is soft and flat. On the basis of this finding, which nursing action is most appropriate?

Accepted Answer

Answer reason: A soft, flat anterior fontanel in a calm infant is an expected assessment finding and does not indicate increased intracranial pressure. Increased intracranial pressure is more consistent with a bulging, tense fontanel (typically with other concerning neurologic signs), which would require escalation. Because the assessment is normal, the appropriate nursing action is routine charting rather than initiating interventions or urgent notification. Increasing fluids targets dehydration (sunken fontanel), and elevating the head of the bed to 90 degrees is unnecessary and could be poorly tolerated in an infant.

Question 46

A nurse assesses a client with myasthenia gravis (MG) who admits with myasthenic crisis. Which action does the nurse take?

Accepted Answer

Answer reason: Myasthenic crisis is an acute exacerbation of neuromuscular weakness that can rapidly progress to ventilatory failure, so immediate airway/breathing assessment is the priority. Evaluating respiratory status (rate, effort, ability to handle secretions, vital capacity/negative inspiratory force if available) determines urgency for ventilatory support and prevents missed impending failure. Applying high-flow oxygen may be supportive but does not address hypoventilation or fatigue and should follow a focused respiratory assessment. Atropine is used for cholinergic toxicity (muscarinic symptoms) rather than myasthenic crisis, and anticholinesterase dosing requires careful differentiation and is not the first action when respiratory compromise is possible.

Question 47

The nurse reviews a client's blood sugars during a diabetes management follow-up. The nurse identifies a pattern of fasting hyperglycemia and suspects Somogyi phenomenon.The nurse asks the client to to take which action?

Accepted Answer

Answer reason: Monitor blood sugars at 3:00 a.m. Somogyi phenomenon is fasting hyperglycemia caused by an unrecognized nocturnal hypoglycemic episode that triggers counterregulatory hormone release and rebound morning hyperglycemia. The key nursing action is to confirm overnight hypoglycemia by checking a glucose value during the typical nadir period (around 2–3 a.m.). Increasing basal insulin could worsen nocturnal hypoglycemia and intensify the rebound pattern rather than correct it. Bedtime snack/exercise changes are not the priority until the overnight glucose pattern is objectively identified.

Question 48

A patient is admitted for a severe head injury and develops dry mucous membranes. The urine output is 400 ml/hr for the last 8-hour shift. Prioritize the nurse's next actions?

Accepted Answer

Answer reason: Severe head injury with very high urine output and dehydration signs strongly suggests diabetes insipidus from impaired ADH, creating risk for rapid free-water loss and hypernatremia. The immediate nursing priority is to validate the suspected complication and quantify severity with focused assessments that guide urgent therapy (dilute urine/low specific gravity and elevated serum sodium/osmolality). These results determine whether desmopressin and IV fluids are indicated and help prevent worsening hypovolemia and neurologic complications from hypernatremia. Starting desmopressin before confirming key labs can mask trends and may be unsafe if an alternate cause of polyuria exists. Notifying the provider is important, but obtaining the most critical assessment data first supports timely, accurate treatment decisions.

Question 49

An insulin-dependent client wakes up at 3:00 am and calls the nurse complaining of slight headache, nausea, and trembling. While the nurse assesses the client, she notices that his extremities are cool and moist. What would be a priority nursing intervention?

Accepted Answer

Answer reason: The key principle is to rapidly assess and confirm suspected hypoglycemia using the fastest reliable bedside method before initiating further actions. The client’s tremors, cool moist skin, and early neuroglycopenic symptoms are classic for low blood glucose, and a fingerstick provides immediate data to guide safe treatment. Sending a stat lab glucose delays clinical decision-making and is unnecessary for initial triage when point-of-care testing is available. Antiemetics/analgesics do not address the likely underlying cause and could postpone appropriate management if the client is truly hypoglycemic.

Question 50

The nurse provides care for a client admitted for elective surgery. The nurse assesses the client's vital signs. How does the nurse position the client for this part of the admission assessment?

Accepted Answer

Answer reason: Accurate baseline vital signs require a standardized position that supports normal cardiopulmonary mechanics and reliable blood pressure measurement. An upright seated posture allows the nurse to place the arm at heart level and reduces positional effects on venous return and respiratory effort that can alter readings. It is also practical for assessing respirations without the client feeling dyspneic from being flat. The side-lying or knees-flexed positions are more appropriate for comfort, certain exams, or procedures, but they are not the preferred standard for routine admission vital signs.

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