Question 1

A 68-year-old is admitted to the surgical unit after undergoing a total hip replacement. Which of the following interventions is most important to prevent dislocation of the prosthesis?

Accepted Answer

Answer reason: The key nursing prevention is maintaining neutral alignment and avoiding the motion that most directly precipitates posterior dislocation. This makes avoiding internal rotation a priority intervention during positioning, transfers, and turning. A common distractor is adduction: keeping the hip adducted actually increases dislocation risk; patients are typically maintained in abduction with a pillow.

Question 2

The client diagnosed with CKD is receiving peritoneal dialysis. Which assessment data warrant immediate intervention by the nurse?

Accepted Answer

Answer reason: Loss of a palpable thrill or audible bruit over a dialysis access suggests impaired blood flow from thrombosis or occlusion, which can rapidly progress to access loss and compromise future dialysis. This requires prompt assessment (check for thrill, evaluate extremity perfusion) and urgent provider notification to restore patency. The other findings describe expected conditions during peritoneal dialysis (soft nontender abdomen with bowel sounds and clear effluent indicating no peritonitis). An equal instill-and-drain volume is not an emergent problem by itself; urgent concern would be poor outflow, abdominal pain, or cloudy effluent.

Question 3

A client is brought to the emergency department after his face slammed into a brick wall during a gang fight. Which client assessment finding is most important for the nurse to consider before inserting a nasogastric tube?

Accepted Answer

Answer reason: In that setting, inserting a nasogastric tube through the nares can track intracranially and cause catastrophic injury, so it is the highest-priority pre-insertion assessment concern. The nurse should avoid nasal tube placement and use an orogastric route (or defer until imaging/clearance) if gastric decompression is needed. Forehead ecchymosis, severe headache, and minor cheek bleeding are important trauma findings but do not specifically create the same direct contraindication to nasal instrumentation as suspected CSF leak.

Question 4

A nurse is preparing the plan of care for the client with a closed fracture of the right arm. Which problem is most appropriate for the nurse to identify?

Accepted Answer

Answer reason: Closed extremity fractures place the client at priority risk for impaired circulation and nerve compromise from swelling, hematoma, or tight immobilization. Planning care should emphasize early detection of ischemia and nerve dysfunction (pain out of proportion, paresthesia, pallor, pulselessness, paralysis, poikilothermia) to prevent irreversible damage. This risk statement broadly captures the highest-safety concern that requires frequent assessment and rapid intervention. Infection from exposed bone/tissue describes an open fracture, not a closed one, making it a less appropriate problem for this scenario.

Question 5

After cataract surgery on the right eye, a client is taught to avoid strain on the operative eye. Which statement by the client indicates a need for further teaching?

Accepted Answer

Answer reason: " After cataract surgery, preventing increased intraocular pressure and avoiding direct pressure on the operative eye reduces the risk of wound dehiscence, hemorrhage, and impaired healing. Sleeping on the operative side can place pressure on the eye/shield and may increase local stress on the surgical site, so it is typically avoided early post-op. The other statements reflect standard post-op precautions: no rubbing (prevents trauma/infection), stool softeners (reduce Valsalva/straining), and avoiding bending at the waist (limits IOP spikes). Therefore this statement signals misunderstanding and need for further teaching.

Question 6

The nurse is caring for 4 clients scheduled to undergo cardiac catheterization for evaluation of chest pain. Which situation should cause the nurse to immediately notify the health care provider?

Accepted Answer

Answer reason: A history of a severe allergy warrants immediate provider notification so premedication, alternative contrast strategies, or additional precautions can be planned before exposing the client to contrast. The other findings are not urgent contraindications: atrial fibrillation is a common comorbidity that can be managed peri-procedurally, creatinine 1.2 mg/dL is generally within/near normal range and not a clear marker of contrast risk by itself, and a glucose of 140 mg/dL is not an emergency. The key safety issue is preventing a potentially life-threatening reaction during the procedure.

Question 7

A client has been discharged to home on parenteral nutrition (PN). With each visit, the home care nurse should assess which parameter most closely in monitoring this therapy?

Accepted Answer

Answer reason: Monitoring temperature helps detect early infection or sepsis associated with the central line and hyperosmolar PN solution. Tracking weight is a sensitive indicator of overall nutritional response and, more urgently, developing fluid overload/dehydration when intake/output tracking at home may be imperfect. Pulse and blood pressure can change late and are less specific for the two most common, high-stakes PN problems than fever and rapid weight change.

Question 8

You performed postoperative stapedectomy teaching several days ago for a client. Which comment by the client concerns you the most?

Accepted Answer

Answer reason: ” After a stapedectomy, avoiding sudden increases in middle-ear pressure is critical to prevent displacement of the prosthesis and perilymph fistula. Frequent coughing (even with the mouth open) creates pressure changes and vibration that can transmit to the surgical site, increasing risk of vertigo, hearing loss, or wound disruption. This statement suggests the client is actively experiencing a risk factor for an acute postoperative complication and may need further assessment and management. In contrast, activities like flying or swimming are typically restricted for a period but are less immediately concerning when planned weeks to months out and if timed after provider clearance.

Question 9

An 82-year-old male client is admitted with benign prostatic hyperplasia (BPH). Which finding by the nurse will require immediate action?

Accepted Answer

Answer reason: In BPH, a bladder volume this large strongly suggests significant retention requiring urgent intervention (e.g., prompt provider notification and likely catheterization per protocol). This finding represents an evolving complication with a clear, time-sensitive pathophysiologic consequence. By comparison, isolated hypertension or mild tachycardia may be important but are not as directly indicative of an obstructive urologic emergency in this context.

Question 10

Which is the most important initial postprocedure nursing assessment for a client who has had a cardiac catheterization?

Accepted Answer

Answer reason: After cardiac catheterization, the most immediate, high-risk complication is hemorrhage/hematoma at the arterial access site, which can rapidly lead to hypovolemia and shock. Early assessment focuses on the puncture site for active bleeding, enlarging swelling, and signs of hematoma so prompt pressure and escalation of care can occur. Lab monitoring is important but is not the first priority in the minutes immediately following the procedure compared with direct assessment for access-site bleeding. Frequent neuro checks are not the primary routine priority unless thromboembolic or sedation-related concerns are present, whereas access-site bleeding risk is universal.

Question 11

The nurse cares for a client who is two weeks postchemotherapy and has a potassium level of 6.5 mEq/L. The nurse questions the health care provider (HCP) regarding which prescriptions?

Accepted Answer

Answer reason: Severe hyperkalemia requires rapid stabilization and shifting potassium intracellularly, while also addressing the underlying cause and ensuring safe elimination. Sodium polystyrene sulfonate enemas are no longer routinely recommended because of limited efficacy for urgent lowering and the risk of serious GI adverse effects, including intestinal necrosis. This risk is particularly concerning in post-chemotherapy clients who may have mucositis, neutropenia, thrombocytopenia, and impaired gut integrity. In contrast, insulin with dextrose provides a faster, temporizing intracellular shift, and bicarbonate may be considered when metabolic acidosis is present, but neither replaces definitive potassium removal measures (e.g., dialysis or loop diuretics when appropriate).

Question 12

An infant client has received an incorrect dose of diazepam. Which is the first action by the nurse caring for this client?

Accepted Answer

Answer reason: Benzodiazepines can rapidly depress the central nervous system and ventilation, and infants are particularly vulnerable to airway obstruction and hypoventilation. The priority is immediate assessment of breathing (rate, effort, oxygen saturation, level of consciousness) to determine whether emergent support is needed. Oxygen may be indicated, but it is an intervention chosen after determining whether there is actual respiratory compromise and whether airway/ventilation support is required. Reporting the error and informing parents are essential follow-up steps, but they do not precede stabilizing and monitoring the infant for life-threatening effects.

Question 13

A patient returns to the surgical unit after a parathyroidectomy. The nurse would anticipate which postoperative order from the physician?

Accepted Answer

Answer reason: Parathyroid removal can abruptly decrease parathyroid hormone, leading to hypocalcemia and potential neuromuscular irritability and laryngospasm. Immediate access to IV calcium supports rapid treatment if acute symptoms such as perioral tingling, tetany, or stridor develop. This is a high-priority postoperative complication risk specific to thyroid/parathyroid surgery and drives anticipatory orders. The other options do not target the most life-threatening expected complication in this setting.

Question 14

The nurse evaluates comprehension of teaching provided to a client scheduled for surgery. Which client response is the most important for the nurse to report to the health care provider?

Accepted Answer

Answer reason: "I hope they keep the operating room cool. My grandfather died during surgery when he got very hot." A personal/family history suggestive of malignant hyperthermia is a high-priority perioperative safety concern because it can be rapidly fatal if not anticipated and treated. This statement implies a possible inherited susceptibility to an anesthetic-triggered hypermetabolic crisis, which requires immediate provider/anesthesia notification and specific precautions (avoid triggering agents, ensure dantrolene availability, enhanced monitoring). The other responses reflect anxiety, curiosity, or general preoperative planning, which warrant support and education but do not signal an imminent anesthesia-related complication. Early identification and communication prevent exposure to triggers and reduce perioperative mortality risk.

Question 15

The nurse is admitting a client who had mastectomy 6 months ago and is scheduled for elective surgery. During the physical assessment, the nurse notices a 0.5 cm mobile, firm, nontender lymph node in the upper arm. What action should the nurse take?

Accepted Answer

Answer reason: The safest nursing action is to facilitate timely workup by anticipating provider orders for tissue diagnosis, because palpation characteristics alone cannot rule out cancer. Cooling measures do not address the cause and can delay evaluation. Empiric antibiotics are not indicated without signs of infection (e.g., warmth, erythema, tenderness, fever), and reassurance that this is “expected” is inappropriate given the risk profile.

Question 16

The nurse is assessing a patient after she underwent a renal arteriogram. The nurse is palpating the right groin access site for complications when the patient suddenly complains of right calf pain. What should the nurse do first?

Accepted Answer

Answer reason: The priority is an immediate focused neurovascular assessment (distal pulses, capillary refill, skin temperature/color, sensation, movement) to detect ischemia and guide urgent escalation. Vital signs are important but do not rule in/out limb-threatening occlusion and can remain normal early. Having the patient stand increases bleeding risk at the puncture site and delays assessment, while sepsis is not the most likely acute complication signaled by isolated sudden calf pain.

Question 17

The nurse is caring for a client with surgical complications who requires continual parenteral nutrition (PN). The nurse assists the health care provider with the insertion of a subclavian triple lumen central venous access device (CVAD). What is the nurse's priority action before initiating the PN infusion?

Accepted Answer

Answer reason: A portable chest x-ray confirms correct tip location and assesses for iatrogenic pneumothorax after subclavian insertion. Starting PN through a malpositioned line can cause extravasation of hyperosmolar solution, thrombosis, or infusion into the wrong vessel, and missing a pneumothorax can delay urgent treatment. While glucose checks, filters, and pump programming are important, they do not supersede confirming safe catheter placement prior to first use.

Question 18

The nurse reviews the most current laboratory results of assigned clients. Which result should the nurse report to the health care provider (HCP) immediately?

Accepted Answer

Answer reason: Pyuria and bacteriuria shortly after transplant strongly suggest a urinary tract infection that requires prompt provider notification for culture, targeted antibiotics, and assessment for complications (e.g., pyelonephritis, sepsis). The mildly elevated WBC count with cellulitis can be expected with localized infection and is not as time-critical without instability. Chronic kidney disease anemia and a modest postprandial glucose elevation are typically managed non-emergently unless accompanied by acute symptoms or severe derangements.

Question 19

The nurse provides discharge instructions to a client who is recovering from testicular cancer surgery. Which instruction should the nurse include?

Accepted Answer

Answer reason: Fever after testicular cancer surgery (e.g., orchiectomy) is an important warning sign that may indicate surgical-site infection, urinary infection, or other postoperative inflammatory complications requiring assessment. This instruction is universally applicable across variations in surgical approach and is a clear safety action for the client. In contrast, activity restrictions like driving or limiting sitting depend on anesthesia recovery, pain control, incision type, and provider-specific guidance and are less consistently correct as a single best instruction.

Question 20

The nurse initiates continuous bladder irrigation on a client who just underwent a transurethral resection of the prostate (TURP). One hour after beginning continuous bladder irrigation, what unexpected assessment finding with the client requires immediate action from the nurse?

Accepted Answer

Answer reason: A very low urine/irrigant return suggests obstruction of the catheter (often by clots) or kinking, which can rapidly lead to acute urinary retention, increasing pain, and worsening bleeding. This is an unexpected high-risk finding that requires immediate nursing actions such as checking tubing for obstruction/kinks, ensuring the bag is below bladder level, and irrigating per protocol/notify provider if unresolved. In contrast, pink urine and some small clots can be expected early after TURP, and mild bladder discomfort can occur with the catheter and irrigation.

Question 21

A client who had an exploratory laparotomy 3 days ago has a white blood cell (WBC) differential with a shift to the left. The nurse instructs unlicensed assistive personnel (UAP) to report which clinical manifestation of this laboratory report?

Accepted Answer

Answer reason: In a post-op client, a new fever is a key systemic sign that may signal evolving infection and requires prompt reassessment and notification of the nurse/provider. Mild redness, swelling, and some drainage can be expected early after surgery and are less specific for infection when isolated. Fever is therefore the most critical manifestation for UAP to report because it may indicate a developing complication needing timely intervention.

Question 22

A nurse cares for a client immediately after mandibular surgery. What does the nurse do when the client develops a runny nose?

Accepted Answer

Answer reason: A key immediate postoperative priority is early recognition and escalation of unexpected findings that may signal a complication. After mandibular/facial surgery, new-onset clear rhinorrhea can indicate a possible cerebrospinal fluid leak from adjacent skull base/sinus involvement, which requires prompt provider evaluation and specific management. Treating it as allergy or simply providing comfort measures risks delaying assessment of a potentially serious complication (meningitis risk). Collecting a nasal specimen is not the initial nursing priority unless specifically ordered after evaluation; the safest action is timely notification for further workup and orders.

Question 23

A nurse cares for a client who is recovering from a bronchoscopy. Which action does the nurse perform?

Accepted Answer

Answer reason: After bronchoscopy, local anesthetic and sedation can blunt protective airway reflexes, creating a high aspiration risk. Nursing care prioritizes verifying gag/swallow reflex has returned before offering oral fluids, food, or oral medications. This action directly reduces the likelihood of aspiration and subsequent respiratory compromise. Early ambulation and breathing exercises may be appropriate later, but they do not address the most immediate post-procedure airway safety concern.

Question 24

A nurse assesses a client who is recovering from a thoracentesis. Which assessment finding is most concerning to the nurse?

Accepted Answer

Answer reason: New or worsening unilateral decreased breath sounds on the procedure side suggests air in the pleural space or lung collapse, which can quickly progress to respiratory distress and requires prompt evaluation and possible chest tube placement. Mild tachycardia and tachypnea can be nonspecific post-procedure findings related to anxiety or pain and are less diagnostic without other instability. Wheezes indicate bronchospasm or airway narrowing but are not the classic red-flag finding for a pleural puncture complication compared with unilateral diminished sounds.

Question 25

The client is admitted following cast application for a fractured ulna. Which finding should be reported to the doctor?

Accepted Answer

Answer reason: Tingling/numbness indicates nerve compression and/or impaired perfusion from a too-tight cast or developing compartment syndrome and requires immediate provider notification for possible cast bivalving or other intervention. Localized pain at the fracture site can be expected initially after casting, whereas warm fingers suggests adequate distal circulation. A rapid pulse is nonspecific and, without clear distal ischemia findings, is less indicative of an urgent cast-related complication than new distal paresthesia.

Question 26

Prior to initiating therapy with unfractionated heparin for a patient hospitalized with a deep vein thrombosis, this treatment requires?

Accepted Answer

Answer reason: Before and during initiation of anticoagulation, the patient is typically kept on bed rest with the affected extremity supported until anticoagulation is therapeutic and symptoms stabilize. Aspirin is not an appropriate substitute/requirement for therapeutic anticoagulation in acute DVT and increases bleeding risk when combined. Fluid restriction and high-protein diet are not required prerequisites for unfractionated heparin and do not address the immediate complication risk in acute DVT.

Question 27

A child is brought to the school nurse after having a permanent tooth knocked out during gym class. Which action by the nurse is appropriate?

Accepted Answer

Answer reason: The tooth should be handled by the crown and only gently rinsed if dirty; scrubbing the root damages the ligament fibers and worsens prognosis. Storing the tooth in water is suboptimal because it is hypotonic and can lyse periodontal ligament cells; timely reimplantation is superior when feasible. Wrapping in dry gauze desiccates the tooth and delays definitive care, increasing the risk of permanent tooth loss and complications.

Question 28

The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother?

Accepted Answer

Answer reason: Moistness and discharge from the umbilical stump can indicate omphalitis, which is a potentially serious neonatal infection requiring prompt in-person assessment. Early evaluation allows inspection for erythema, swelling, foul odor, tenderness, and systemic signs, and enables timely cultures and antibiotics if indicated. Reassuring the parent or delaying reassessment risks progression to cellulitis, sepsis, or necrotizing infection in a vulnerable newborn. Increasing cleaning frequency is not appropriate because it may further irritate tissue and does not address a possible infection source.

Question 29

The nurse is instructing a client with diabetes mellitus about peritoneal dialysis. The nurse tells the client that it is important to maintain the prescribed dwell time for the dialysis because of the risk of which complication?

Accepted Answer

Answer reason: If dwell time is longer than prescribed, there is greater time for glucose absorption, increasing the risk of elevated serum glucose levels. This is a predictable metabolic complication of peritoneal dialysis and is addressed by adhering to the ordered exchange schedule and monitoring glucose. Peritonitis is related mainly to breaks in aseptic technique, and disequilibrium syndrome is classically associated with hemodialysis rather than peritoneal dialysis.

Question 30

A nurse is teaching the parents of a pre-schooler about the possibility of postoperative hemorrhage after a tonsillectomy and adenoidectomy. When should the nurse explain that the risk of bleeding is the greatest?

Accepted Answer

Answer reason: This typically happens about a week post-op, exposing fragile granulation tissue and small vessels that can reopen and bleed. Teaching parents this timeframe helps them recognize that a child who starts frequent swallowing, spitting blood, or vomiting blood around this period needs urgent evaluation. Earlier bleeding is possible but is more associated with immediate surgical hemostasis issues, whereas the peak risk for delayed bleeding is around the time the scab separates.

Question 31

A mother of a child with mumps calls the health care clinic to tell the nurse that the child has been lethargic and vomiting. What instruction should the nurse give to the mother?

Accepted Answer

Answer reason: Mumps is usually self-limited, so a change in level of alertness or persistent vomiting should prompt timely in-person assessment rather than reassurance. Advising simple monitoring or stating these are “normal” minimizes potentially urgent symptoms and delays care. Absence of fever does not rule out significant complications or fluid deficit, so the child still needs evaluation.

Question 32

An orthopedic nurse is caring for a patient that had a right total hip replacement. Which observations by the nurse require further education?

Accepted Answer

Answer reason: After total hip arthroplasty, the key safety principle is preventing hip dislocation by avoiding hip adduction and internal rotation, especially early in recovery. Crossing the legs places the operative hip into adduction, which increases dislocation risk and indicates the patient is not following hip precautions. Using an abduction pillow supports neutral alignment during sleep, and asking someone else to pick up a dropped item helps avoid unsafe bending past hip flexion limits. Stair technique described is consistent with protecting the operative limb by leading with the non-affected leg and using an assistive device.

Question 33

Because of steroid excess after a bilateral adrenalectomy, the nurse should assess the client for?

Accepted Answer

Answer reason: Excess glucocorticoids impair immune function and inhibit fibroblast activity and collagen synthesis, which directly slows tissue repair after surgery. They also cause protein catabolism and thin skin, further reducing wound tensile strength and increasing risk of dehiscence and infection. Therefore the most expected complication to monitor is poor or delayed incision healing. Postoperative confusion is more commonly related to hypoxia, medications, or metabolic issues rather than steroid excess, and emboli are not a characteristic direct consequence of corticosteroid excess in this context.

Question 34

The nurse is interviewing a male client with hypertension. Which additional medical diagnosis in the client's history presents the greatest risk of developing a cerebrovascular accident (CVA)?

Accepted Answer

Answer reason: In a patient who already has hypertension, the combination markedly increases cerebrovascular risk through additive vascular injury and higher likelihood of carotid and intracranial arterial disease. Parkinson’s disease and hypothyroidism are not primary drivers of cerebrovascular atherothrombotic events compared with diabetes. Recurring pneumonia may signal frailty but does not confer the same direct, sustained vascular risk for CVA as diabetes does.

Question 35

A client in labor at 39 weeks gestation was admitted to the labor and delivery unit. The client is ambulating in the hallway to facilitate labor progression when she tells the nurse, "My water broke." Which of the following should be the nurse's priority action?

Accepted Answer

Answer reason: Moving the client to the labor room allows prompt evaluation and immediate interventions if a nonreassuring pattern is found. Fetal heart rate assessment directly detects cord compression or sudden hypoxia, which are time-critical threats. Notifying the provider and checking fluid characteristics are important but occur after the fetus is assessed and stabilized. Vital signs address maternal status but do not identify the most urgent potential complication right after membrane rupture.

Question 36

The nurse receives report for a client at 36 weeks gestation who is being transferred to the unit for labor induction from a rural health care facility with an intrauterine fetal demise of unknown duration. Which intervention is most important when receiving care of the client?

Accepted Answer

Answer reason: Establishing coagulation status (including fibrinogen, which is often low early in obstetric DIC) and platelet count is the priority to prevent hemorrhagic complications during induction and delivery. Uterine activity assessment and starting oxytocin are important but are unsafe if significant coagulopathy is present and unrecognized. Psychosocial support such as chaplain services is appropriate, but it does not supersede immediate assessment for life-threatening bleeding risk.

Question 37

A client who experienced a fractured right ankle has a short leg cast applied in the emergency department. During discharge teaching, which information should the nurse provide to the client to prevent complications?

Accepted Answer

Answer reason: Early elevation reduces dependent edema and helps prevent neurovascular compromise from swelling under a new cast. Keeping the extremity above heart level promotes venous and lymphatic return, decreasing pain and pressure that can progress to compartment-like symptoms. In contrast, burning/tingling is an abnormal warning sign that should prompt evaluation rather than reassurance, and weight bearing depends on explicit provider orders, not cast “dryness.” Clients should also not trim or alter the cast themselves because it can damage padding and create pressure points leading to skin breakdown.

Question 38

A nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client?

Accepted Answer

Answer reason: Upright positioning (sitting or elevating the HOB) optimizes diaphragmatic excursion and lung volumes, allowing more effective sustained inhalation. A tight seal is needed (not a loose seal) to ensure adequate negative pressure and volume achievement, and inhalation should be slow and deep rather than rapid. Typical breath-hold is about 3–5 seconds after maximum inspiration, making the 15-second hold inaccurate and potentially uncomfortable.

Question 39

A nurse cares for a client receiving a heparin infusion. The nurse observes bright red urine in the client's catheter drainage system. Which action does the nurse take first?

Accepted Answer

Answer reason: Bright red urine while on a heparin infusion suggests active bleeding from over-anticoagulation, so the priority is to rapidly assess the severity and guide immediate management with objective data. Coagulation studies (especially aPTT and related labs per protocol) confirm whether the infusion has produced supratherapeutic anticoagulation and help determine the next steps. Changing the infusion rate or preparing protamine are treatment actions that should be based on verified coagulation status and institutional protocols. The provider should be notified promptly, but obtaining critical labs first supports faster, safer decision-making and escalation.

Question 40

A client with severe blood loss resulting from multiple trauma requires rapid transfusion of several units of blood. The nurse asks another health team member to obtain which device for use during the transfusion procedure to help reduce the risk of cardiac dysrhythmias?

Accepted Answer

Answer reason: Using a blood warmer helps maintain normothermia during massive or rapid transfusion, directly reducing this dysrhythmia risk. A cardiac monitor detects dysrhythmias but does not prevent the temperature-related trigger. An infusion pump and pulse oximeter support delivery/monitoring but do not address hypothermia as the modifiable cause in this scenario.

Question 41

You are working in an ambulatory care clinic. A client calls to report redness of the sclera, itching of the eyes, and increased lacrimation for several hours. What should you direct the caller to do first?

Accepted Answer

Answer reason: " Immediate risk reduction is the priority when a patient reports acute eye redness, itching, and tearing because contact lenses can worsen irritation and increase the risk of corneal abrasion or infectious keratitis. Removing lenses eliminates ongoing mechanical and microbial insult and allows the ocular surface to recover while symptoms are further assessed. Symptomatic measures like cool compresses or antihistamines may help allergic conjunctivitis but should come after removing a potential aggravating factor. Simply referring the patient without any first-aid guidance fails to address an avoidable complication in the moment.

Question 42

The nurse cares for a client following transsphenoidal hypophysectomy. The nurse is alert for which signs that may indicate cerebral spinal fluid (CSF) leakage?

Accepted Answer

Answer reason: This subtle behavior change can be an early bedside clue before more severe complications develop. Headache with fever and nuchal rigidity is more consistent with meningitis, which is a possible consequence of a CSF leak but not the earliest sign of leakage itself. Dry mucous membranes suggests dehydration, and decreased sense of smell is related to nasal/olfactory nerve irritation rather than CSF leakage.

Question 43

A nurse cares for a client who has had prolonged nasogastric intubation with gastric suctioning. The client reports new leg cramping, and the nurse finds the client has 4+ deep-tendon reflexes. Based on these findings, what is the priority nursing action?

Accepted Answer

Answer reason: Prolonged gastric suctioning can cause electrolyte losses (notably magnesium and potassium) and metabolic alkalosis, which increase neuromuscular excitability. Leg cramps with markedly hyperactive deep-tendon reflexes signals significant irritability with risk for tetany and progression to seizures, making immediate safety measures the priority. Seizure precautions reduce the risk of injury while the provider is notified and labs/replacement therapy are initiated. Assessing for Chvostek/Trousseau can support suspicion of hypocalcemia, but it does not address the most immediate threat to safety. Turning off suction or giving a muscle relaxant does not correct the underlying electrolyte imbalance and could delay urgent protective care.

Question 44

Which instruction should the nurse expect to include in the discharge teaching plan for the parent of an infant who has had an inguinal herniorrhaphy?

Accepted Answer

Answer reason: Postoperative teaching for an infant after inguinal hernia repair prioritizes preventing contamination and infection of the groin incision. Prompt diaper changes reduce exposure of the surgical site to urine and stool, which are major sources of moisture and bacteria that can impair healing. Routine use of abdominal binders is not standard for infants after this procedure and can add discomfort or pressure without clear benefit. Keeping the incision continuously covered with a sterile dressing at home is typically unnecessary unless specifically ordered, and routine hand restraints are inappropriate; instead, caregivers should use supervision and comfort measures to reduce picking at the site.

Question 45

A client is admitted with a diagnosis of renal calculi. The client reports moderate-to-severe flank pain and nausea. The client’s oral temperature is 100.8 F (38.2 C). Which of these goals is the priority nursing focus for this client?

Accepted Answer

Answer reason: The priority nursing goal is to prevent and promptly address infection-related complications by closely monitoring for systemic deterioration and facilitating timely diagnostics and treatment. Pain and nausea management are important but are secondary to identifying and mitigating a potentially life-threatening infectious process. Maintaining fluid balance supports stone passage, yet it does not supersede the need to address possible infection when fever is present.

Question 46

The nurse is evaluating a client with liver cirrhosis who received IV albumin after a paracentesis to drain ascites. Which assessment finding indicates that the albumin has been effective?

Accepted Answer

Answer reason: IV albumin is a plasma expander that increases intravascular oncotic pressure, pulling fluid from the interstitial/third-spaced compartment back into the circulation after large-volume paracentesis. The key desired outcome is prevention of paracentesis-induced circulatory dysfunction, which would present as hypotension, tachycardia, and other signs of intravascular volume depletion. Stable vital signs therefore best reflect effective intravascular volume support. A reduced abdominal girth reflects fluid removal from the procedure itself rather than the specific effectiveness of albumin, and asterixis relates to hepatic encephalopathy rather than volume status.

Question 47

The emergency nurse admits a semiconscious client with potential bruising and severe tongue edema after a laceration sustained in an unwitnessed tonic-clonic seizure. The health care provider prescribes a nasopharyngeal airway to maintain airway patency. Which initial action by the nurse is appropriate?

Accepted Answer

Answer reason: A nasopharyngeal airway can cause nasal mucosal trauma and significant epistaxis, especially in patients with coagulopathy or antiplatelet/anticoagulant exposure. With potential facial/nasal trauma after an unwitnessed seizure, checking for bleeding risk is a key safety step before insertion to prevent avoidable hemorrhage and airway compromise from blood. Size selection is important but does not address the highest immediate complication risk in this context. Auscultating lungs assesses ventilation after placement but is not the priority “before you insert” safety screen compared with bleeding risk.

Question 48

An infant has been found to be human immunodeficiency virus (HIV) positive. When teaching condition-specific care, which action should the nurse instruct the mother to take to minimize the child’ risk for condition-related injury?

Accepted Answer

Answer reason: HIV causes immunosuppression, increasing an infant’s risk for skin breakdown and secondary bacterial or fungal infections from minor irritation. Frequent diaper changes and meticulous perineal care reduce moisture, maceration, and colonization that can rapidly progress to dermatitis and infection in an immunocompromised child. This directly prevents a common, condition-related source of injury (skin integrity loss) and its complications. The other options address problems not specifically increased by HIV status (e.g., aspiration technique, aerophagia/colic measures, or signs of increased intracranial pressure).

Question 49

The nurse would determine that a postoperative patient is not receiving the beneficial effects of enoxaparin (Lovenox) after noting what during a routine shift assessment?

Accepted Answer

Answer reason: New unilateral leg pain and swelling are classic assessment findings of DVT, indicating the prophylactic benefit is not being achieved (or that a clot has developed despite prophylaxis). This finding is more directly tied to failure of anticoagulant prevention than nonspecific symptoms like generalized weakness. Crackles suggest atelectasis or fluid overload rather than a clear sign of ineffective DVT prophylaxis, and decreased bowel sounds more strongly suggests ileus.

Question 50

The patient had aortic aneurysm repair. What priority nursing action will the nurse use to maintain graft patency?

Accepted Answer

Answer reason: Maintaining graft patency after aortic aneurysm repair depends on ensuring adequate perfusion pressure and flow through the new graft to prevent thrombosis/occlusion. IV fluids are a rapid, titratable way to support circulating volume and stabilize blood pressure, especially in the immediate postoperative period when bleeding or third-spacing can reduce perfusion. Intentionally keeping blood pressure low can compromise distal circulation and increase risk of graft occlusion and organ ischemia. Monitoring urine output is important for detecting renal hypoperfusion, but it is an assessment rather than the primary action to maintain patency.

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