Question 1

An elderly patient had surgery two days for an intestinal obstruction. Vital signs at 10 am are temperature 37.5 c (99.5 f), heart rate 86, respiratory rate 16 blood pressure level 132/72 mm Hg, pain level of 4 on a scale of 0 to 10. The abdominal dressing is dry and intact. The nasal gastric tube to low intermittent suction. The patient is on strict input and output every two hours. At 12.20 pm, the patient complains abdominal pain, upon assessment the vital signs are temperature 37.5 C, heart rate 98, respiration rate 24, blood pressure level 146/ 88 mm Hg, pain level is 8 out of 10. The patient abdomen is distended and rigid, the dressing remains dry and intact. The nurse should first?

Accepted Answer

Answer reason: A nasogastric tube that is not patent can rapidly worsen gastric/intestinal distention, increasing pain and respiratory rate and raising the risk of vomiting/aspiration. Checking patency by irrigating per protocol is a rapid, focused intervention that addresses a reversible cause while guiding urgent escalation of care if symptoms persist. Giving analgesia first can mask worsening abdominal findings and delay recognition of deterioration. Increasing suction or repositioning are secondary steps and should follow confirmation that the tube is functioning correctly and provider notification as indicated.

Question 2

The nurse is caring for a patient who is scheduled for elective cardioversion. The nurse is reviewing the patient's information and chart. Which of the following findings should the nurse inform the physician of immediately?

Accepted Answer

Answer reason: A documented atrial clot is therefore an urgent contraindication to proceeding until the provider reassesses and anticoagulation/TEE-guided management is addressed. Anticoagulation history (e.g., heparin use) and a history of atrial fibrillation are expected considerations but do not, by themselves, represent an immediate stop-risk like a known thrombus. Holding digoxin prior to cardioversion may be relevant for dysrhythmia risk, but it is not as immediately dangerous as cardioverting in the presence of an atrial clot.

Question 3

A 4-year old boy is recovering from abdominal surgery at the pediatric unit. As the nurse caring for the child, which activity would be most beneficial for him?

Accepted Answer

Answer reason: Postoperative children are at risk for atelectasis due to pain-limited ventilation and shallow breathing, so nursing care should promote deep breathing in a developmentally appropriate way. This play activity encourages slow, sustained exhalation and naturally increases depth of respiration, improving alveolar expansion and secretion mobilization without requiring complex instruction. It is feasible for a 4-year-old and minimizes strain on the abdominal incision compared with more active play. Peek-a-boo is more appropriate for infants, while blocks or clay may distract but do not specifically support pulmonary hygiene after surgery.

Question 4

A woman who delivered a healthy baby 6 hours ago tells the nurse that she is having cramps in her legs. Upon further assessment, the nurse identifies leg pain on dorsiflexion. The nurse should?

Accepted Answer

Answer reason: Pain on dorsiflexion postpartum is a classic concerning finding for possible deep vein thrombosis, and suspected DVT requires prompt medical evaluation to prevent pulmonary embolism. The safest nursing action is to escalate care rather than perform interventions that could dislodge a clot. Massage is contraindicated because it may mobilize a thrombus, and warm compresses/ankle pumps are not appropriate while DVT is suspected. Prompt notification supports timely diagnostic testing and initiation of anticoagulation if indicated.

Question 5

A nurse is evaluating a client with a temporary pacemaker. The patient’s ECG tracing shows each P wave followed by the pacing spike. The nurse’s best response is which of the following?

Accepted Answer

Answer reason: A pacing spike should precede the depolarization it is intended to trigger; seeing a P wave before the spike indicates inappropriate timing (undersensing) or ineffective atrial pacing in a patient who is conducting intrinsically. The safest immediate nursing action is to troubleshoot the temporary pacer system, starting with verifying lead and generator connections and then adjusting output to ensure reliable capture if pacing is still required. Increasing the milliampere is a standard first-line adjustment when capture is questionable because it raises stimulus strength above threshold. Simply documenting/observing delays correction of a potentially unstable pacing problem, and additional diagnostics are secondary after immediate pacer function assessment and stabilization.

Question 6

The wife of a man who sustained an eye injury calls the emergency department and speaks to the nurse. The wife reports that her husband was hit in the eye area by a piece of board while building a shed in the backyard. The nurse should advise the wife to take which immediate action?

Accepted Answer

Answer reason: Blunt trauma to the eye/orbital area is managed initially by limiting swelling and pain while avoiding added pressure or manipulation that could worsen occult injury. Cold application helps reduce edema and hematoma formation, which can also improve subsequent assessment and comfort. Irrigation is appropriate for chemical or particulate foreign-body exposures, not a direct blow from a board. The client should still be evaluated urgently in the ED, but the immediate home action is local cold application while arranging prompt care and monitoring for vision changes or severe pain.

Question 7

The nurse provides discharge instructions to a client with Cushing syndrome. The nurse advises the client to follow which instruction?

Accepted Answer

Answer reason: " Hypercortisolism increases the risk of gastrointestinal mucosal injury and bleeding, and chronic steroid exposure can mask early inflammatory symptoms, so patients need teaching to recognize occult blood loss. Dark, tarry stools indicate possible upper GI bleeding (melena) and warrant prompt evaluation. Adding salt would worsen sodium and water retention and hypertension commonly seen with this disorder. Weekly weight checks are too infrequent for monitoring fluid shifts; daily weights are typically emphasized instead.

Question 8

The nurse has reinforced teaching with a client who was placed in skeletal traction 24 hours ago for a fractured femur. It would indicate a correct understanding of the teaching if the client?

Accepted Answer

Answer reason: This action supports rapid evaluation for impaired perfusion or nerve compression (e.g., developing compartment syndrome) before irreversible damage occurs. Rolling side to side can disrupt traction alignment and is not routinely done without maintaining body alignment and traction integrity. Resting feet against the end of the bed promotes foot drop, and adjusting traction ropes/weights is a nursing responsibility because changing the setup can negate the therapeutic pull and cause injury.

Question 9

Which client should the nurse assess first after receiving the hand-off morning report?

Accepted Answer

Answer reason: This is an immediate patient-safety concern requiring prompt assessment, holding infusions, and notifying the provider for verification of tip location before further use. In contrast, absent bowel sounds on postoperative day 1 is commonly expected with ileus and is typically monitored unless accompanied by acute deterioration (e.g., severe pain, distention, instability). The other situations indicate ongoing management or education needs but are less time-critical than a potentially malpositioned central line.

Question 10

The PN is caring for a client who is 24 hours postoperative for a hemicolectomy with temporary colostomy placement. On assessment, the PN finds that the stoma is dry and dark red. Based on this finding, what action should the nurse take?

Accepted Answer

Answer reason: A newly created stoma should appear moist and beefy red/pink, reflecting adequate perfusion. Dryness with a dark red color suggests impaired circulation and possible ischemia/necrosis, which is an early postoperative complication requiring prompt medical evaluation. Immediate escalation is the safest action because delayed intervention can result in tissue loss and further surgical complications. Documentation is important but is not the priority over timely notification, and adjusting the pouch or applying petroleum gauze does not address the underlying perfusion problem and could delay definitive care.

Question 11

A nurse is assigned to care for a client who just underwent a thyroidectomy. The nurse notes that the client has developed peripheral numbness and tingling, muscle twitching and spasms. With this, the nurse anticipates to administer?

Accepted Answer

Answer reason: Post-thyroidectomy numbness/tingling with muscle twitching and spasms strongly suggests hypocalcemia due to inadvertent removal or stunning of the parathyroid glands, causing decreased PTH and neuromuscular irritability (tetany). Immediate treatment for symptomatic hypocalcemia is IV calcium (commonly calcium gluconate) to rapidly stabilize the myocardium and reduce tetanic symptoms. Thyroid hormone replacement addresses hypothyroidism but would not acutely correct neuromuscular excitability. Sedatives or antispasmodics may mask symptoms while delaying definitive correction of the electrolyte complication and do not treat the underlying cause.

Question 12

A nurse is caring for an older adult client. The nurse should inform the client that straining while defecating can cause which of the following?

Accepted Answer

Answer reason: This can produce bradycardia, hypotension, syncope, and conduction changes that may precipitate cardiac rhythm disturbances, especially in older adults with underlying cardiac disease. The clinical risk is therefore cardiovascular instability rather than gastrointestinal pathology. The other options do not reflect typical physiologic consequences of a Valsalva/vagal episode.

Question 13

A female client diagnosed with lung cancer is to have a left lower lobectomy. What increases the client’s risk of developing postoperative pulmonary complications?

Accepted Answer

Answer reason: Height is 5 feet, 7 inches (170.2 cm) and weight is 110 lb (49.9 kg). Poor nutritional status/low body weight decreases protein reserves and immune function, which impairs wound healing and the ability to clear secretions after thoracic surgery. After a lobectomy, effective cough, respiratory muscle strength, and tissue repair are essential to prevent atelectasis and pneumonia; underweight clients are at higher risk for these complications. By contrast, being able to climb a flight of stairs without dyspnea suggests adequate functional reserve and lowers pulmonary risk. Age 58 alone is not a major standalone risk factor compared with malnutrition, and emotional reserve does not directly increase physiologic pulmonary complication risk.

Question 14

A nurse is caring for a client diagnosed with an unstable spinal cord injury at the T-7 level. Which intervention should take priority during the planning of care?

Accepted Answer

Answer reason: A pressure-reducing surface is a priority preventive measure because it continuously decreases interface pressure when turning/repositioning may be limited by spinal precautions. Calorie and fluid increases support recovery but do not address the most imminent, preventable complication arising from restricted mobility. Incontinence skin products are helpful, but pressure relief is the primary driver of early pressure-injury prevention in this context.

Question 15

While working on a pediatric floor, your 2-year old patients begins experiencing epistaxis. Place the appropriate priority nursing actions in the correct sequence?

Accepted Answer

Answer reason: Upright positioning with a forward lean promotes drainage out of the nares rather than into the pharynx, decreasing gagging, vomiting, and airway compromise in a toddler. After positioning, continuous firm pressure to the soft part of the nose for at least 10 minutes is the key hemostatic measure; ice is only adjunctive vasoconstriction. Packing with cotton is not an initial nursing priority in a young child and can increase mucosal trauma or pose a choking/aspiration risk if dislodged.

Question 16

The nurse is talking with a client who has diabetes mellitus (type 1) and is receiving prescribed insulin via an infusion pump. Which of the following statements by the client would require follow-up?

Accepted Answer

Answer reason: " Insulin pump therapy uses rapid/short-acting insulin with continuous basal delivery, so interruption or misdosing can quickly cause significant hyperglycemia and even diabetic ketoacidosis. Safe self-management requires frequent glucose checks (often before meals/bedtime and as needed, or continuous monitoring) to guide boluses and detect infusion-set failure early. Reducing monitoring to only twice daily increases the risk of unrecognized hypo/hyperglycemia and delayed response to pump malfunction. In contrast, taking a pre-meal bolus and changing the infusion set every 2–3 days are standard pump practices.

Question 17

Your elderly patient chokes whenever she is given oral fluids. You should?

Accepted Answer

Answer reason: Thickened liquids often improve bolus control and decrease the chance of aspiration compared with thin liquids. A formal swallowing study (typically by speech-language pathology) identifies the safest consistencies and techniques for oral intake and guides diet modifications. “Push oral fluids” increases aspiration risk, and PT/OT consults do not directly assess swallowing safety in the moment.

Question 18

The nurse provides care for four clients on a medical surgical unit. The nurse knows that which client is at risk for wound dehiscence and evisceration?

Accepted Answer

Answer reason: Wound dehiscence and evisceration are most likely to occur after abdominal surgery, especially in clients with impaired wound healing. Diabetes mellitus and obesity delay healing, reduce tissue perfusion, and increase the risk of infection. Because this client is obese, diabetic, and only 1 day postoperative from an abdominal procedure (appendectomy), this client is at the greatest risk.

Question 19

The nurse is caring for a client who had an orthopedic injury of the leg that required surgery and the application of a cast. Postoperatively, which nursing assessment is of highest priority to assure client safety?

Accepted Answer

Answer reason: Checking capillary refill via nail-bed blanching is a rapid indicator of distal perfusion and helps detect early compartment syndrome or a cast that is too tight. Delayed refill or poor blanching response signals impaired arterial flow requiring urgent intervention to prevent ischemia and permanent tissue damage. Heel breakdown is important but develops over time; bladder distention is not specific to the casted extremity. Extremity shortening relates more to alignment/traction concerns and is less acute than perfusion assessment for immediate safety.

Question 20

The nurse is measuring the chest tube drainage of a patient who had open heart surgery 4 hours ago. Which of the following is the MAXIMUM hourly amount of chest tube drainage is expected in this timeframe?

Accepted Answer

Answer reason: A commonly used upper expected threshold in the first several postoperative hours is about 200 mL per hour; beyond this, the nurse should notify the surgeon and anticipate evaluation for ongoing bleeding/coagulopathy. This level aligns with normal immediate post-op oozing from surgical sites while still allowing timely detection of abnormal blood loss. Lower values may occur but are not the maximum expected, while substantially higher amounts raise concern for complications rather than expected findings.

Question 21

Which newborn infant would warrant immediate intervention by the nursery nurse?

Accepted Answer

Answer reason: Failure to pass meconium within the first 24 hours is abnormal and can indicate bowel obstruction or other gastrointestinal pathology that can rapidly become serious. This finding warrants prompt assessment of abdominal distention, feeding intolerance, vomiting (especially bilious), and patency of the anus, and escalation to the provider for further evaluation. In contrast, abundant lanugo is a normal newborn finding, respirations of 52/min are within the expected newborn range (about 30–60/min) when unlabored, and turning red while crying can be a normal response without signs of respiratory distress. Prioritizing early detection of obstruction prevents complications such as dehydration, electrolyte imbalance, and perforation.

Question 22

The nurse is caring for a client with end-stage liver disease who was admitted for bleeding esophageal varices. The bleeding varices were banded successfully, but the client declined having a transjugular intrahepatic portal-systemic shunt (TIPS) procedure and opted for do not resuscitate (DNR) status. Which topic is most important for the nurse to discuss with the client and family at discharge?

Accepted Answer

Answer reason: Promptly contacting the HCP/emergency services with any hematemesis, melena, dizziness, or syncope enables rapid stabilization and definitive management before decompensation occurs. Abstinence from alcohol and correct medication use are important long-term measures but do not address the immediate high-risk post-discharge emergency. A DNR order guides actions during cardiopulmonary arrest and does not replace the need to seek emergent care for potentially reversible bleeding.

Question 23

The nurse is caring for a client diagnosed with type 1 diabetes mellitus. Because the client is at risk for hypoglycemia, which instructions should the nurse teach the client to follow?

Accepted Answer

Answer reason: Hypoglycemia requires immediate access to a fast-acting carbohydrate to rapidly raise blood glucose and prevent progression to seizure or loss of consciousness. Glucose tablets provide a measured dose of simple sugar that can be taken quickly at the first symptoms, aligning with standard self-management teaching for type 1 diabetes. Urine acetone monitoring is aimed at detecting ketosis/DKA from hyperglycemia rather than preventing or treating hypoglycemia. Omitting scheduled intermediate-acting insulin after exercise is unsafe without provider guidance; exercise generally requires planned carbohydrate intake and/or individualized dose adjustment to avoid wide glucose swings.

Question 24

The nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse determines that the client needs further instructions if the client made which statement?

Accepted Answer

Answer reason: PICC teaching emphasizes preventing infection, dislodgement, and catheter damage while allowing normal daily activity within safe limits. Clients are generally encouraged to continue usual activities, avoiding heavy lifting, repetitive vigorous arm motions, or contact sports that could kink or pull the line, rather than broadly restricting all activity. Protecting the site from water exposure and checking external catheter length/markings help detect dislodgement and reduce contamination risk. Wearing a medical alert identifier is appropriate because it informs providers of central venous access in emergencies and can prevent unsafe procedures in that arm.

Question 25

A hospitalized client is scheduled for a percutaneous kidney biopsy at 10 AM. At 8 AM, the nurse reviews the client's vital signs and most current serum laboratory results. Which finding is most important to report to the health care provider (HCP)?

Accepted Answer

Answer reason: This reading is in the severe range and would typically require treatment and possible delay of the procedure until better controlled. While creatinine may be elevated due to underlying renal disease (often the reason for biopsy), it does not by itself create an immediate procedural safety contraindication. Mild anemia and a platelet count of 120,000/mm3 are concerning but are generally less urgent than severe hypertension in predicting acute bleeding complications for this procedure.

Question 26

The nurse is monitoring a 3-year-old child for signs and symptoms of increased intracranial pressure (ICP) after a craniotomy. The nurse plans to monitor for which early sign or symptom of increased ICP?

Accepted Answer

Answer reason: It can occur before late findings such as widening pulse pressure, bradycardia, or abnormal respirations. In a 3-year-old, a bulging anterior fontanel and increasing head circumference are unlikely because the fontanels are typically closed and cranial sutures are fused enough that head size does not rapidly expand. Headache can occur, but young children may not reliably localize or verbalize it, whereas vomiting is more observable and clinically actionable as an early change.

Question 27

The nurse is caring for a client immediately after a paracentesis. It is MOST important for the nurse to ask which of the following questions?

Accepted Answer

Answer reason: Large-volume paracentesis can cause acute intravascular volume shifts with hypotension, making early detection of hemodynamic instability the priority. Asking about dizziness quickly screens for symptomatic hypotension that may require immediate vital-sign assessment, positioning, and possible fluid/albumin support per protocol. Pain can occur, but severe post-procedure pain is less common and typically follows initial stability checks. “Clothes still feel tight” is a delayed, non-urgent assessment of ascites relief, and urinary urgency is not a primary immediate post-paracentesis safety concern.

Question 28

The nurse is caring for a postoperative client who has just returned from the postanesthesia care unit after having nasal surgery. What priority action is essential for the nurse to perform?

Accepted Answer

Answer reason: This complication can rapidly threaten the airway and lead to aspiration, hypovolemia, or shock, so it warrants immediate focused assessment on return from PACU. External packing can appear minimally soiled even when significant internal bleeding is occurring, making it less reliable as a first priority. Vital signs are important but can lag behind early occult bleeding, so targeted assessment for concealed hemorrhage is the essential immediate action.

Question 29

A client has just undergone endoscopy. Which is the essential postprocedure nursing intervention?

Accepted Answer

Answer reason: Endoscopy commonly involves topical pharyngeal anesthesia and sedation, which temporarily depress protective airway reflexes. The key immediate risk post-procedure is aspiration if oral intake is started before the swallow and gag reflexes return. Verifying the gag reflex (and ability to swallow) provides direct evidence that the airway is protected before offering food or fluids. Clear liquids for 24 hours is unnecessary for most routine upper endoscopies, and positioning alone does not address the core aspiration risk.

Question 30

Before administering a nasogastric feeding to a preterm infant, the nurse aspirates residual fluid from the stomach. Place the following actions in order?

Accepted Answer

Answer reason: Aspiration prevention is the priority when initiating or resuming enteral feedings, especially in preterm infants who have immature airway-protective reflexes. Elevating the head before handling residuals and starting the feed reduces reflux and the risk of aspiration during the procedure. After positioning, the nurse measures the residual to assess gastric emptying and feeding tolerance, then typically returns the aspirate to avoid fluid/electrolyte loss and adjusts the feeding volume accordingly. Starting the feeding is performed only after these safety checks and volume adjustments are completed.

Question 31

Which observation of an 8-pound, 4-ounce neonate, if made by an RN, would require an intervention?

Accepted Answer

Answer reason: The neonate’s axillary temperature is 96.2°F (35.6°C). Newborns are prone to heat loss and should be maintained in a neutral thermal environment; an axillary temperature below about 97.7°F (36.5°C) indicates hypothermia that requires nursing action. Hypothermia increases oxygen consumption and can precipitate hypoglycemia, metabolic acidosis, and respiratory distress, so warming measures and reassessment are needed promptly. By contrast, periodic breathing with mild irregularity and a rate in the normal range for a term neonate can be a normal finding when there are no signs of distress. Visible apical impulse at the left 5th intercostal space and asymmetric extremity movements can be normal newborn variants depending on overall assessment.

Question 32

Which of the following clients is at greatest risk for impaired vascular perfusion?

Accepted Answer

Answer reason:Hypertension is a major risk factor for impaired vascular perfusion because chronic high blood pressure damages blood vessel walls, accelerates atherosclerosis, and reduces blood flow to vital organs. This increases the risk of complications such as peripheral arterial disease, stroke, coronary artery disease, and kidney disease.

Although smoking (Option C) is also a significant risk factor, hypertension has a more direct and widespread effect on vascular perfusion.

Question 33

The nurse monitors for which acid-base imbalance in the client who has received six units of packed red blood cells in the past 6 hours secondary to blood loss in surgery?

Accepted Answer

Answer reason: Massive/rapid transfusion in the setting of ongoing hemorrhage can contribute to decreased tissue perfusion and lactic acid production, creating a metabolic acid load. In addition, large-volume transfusion and shock physiology commonly lead to acidemia until perfusion and ventilation are stabilized. This makes an acidosis of metabolic origin the key imbalance to monitor with ABGs and lactate. Respiratory disorders would be driven primarily by hypoventilation or hyperventilation rather than the perfusion and transfusion-related metabolic changes seen here.

Question 34

A 2-year-old child who has abdominal pain is diagnosed with intussusception. A hydrostatic reduction has been performed. Which finding should be reported immediately before surgery proceeds?

Accepted Answer

Answer reason: This is a key change in status that can alter the plan of care because successful nonoperative reduction can make immediate surgery unnecessary. The nurse should urgently communicate this finding so the team can reassess for ongoing symptoms and confirm reduction rather than proceeding automatically to an operative intervention. In contrast, findings like currant jelly stools or a sausage-shaped mass are classic for active intussusception and do not by themselves signal resolution.

Question 35

A client who has had a hemiglossectomy and radical right neck dissection arrives in the post anesthesia care unit with two portable drainage catheters in the area of the incision which are attached to Hemovacs. Six hours later one Hemovac accumulates 180 mL of serosanguineous drainage. The priority nursing intervention should be to?

Accepted Answer

Answer reason: A drainage volume like 180 mL over 6 hours can be plausible after extensive head/neck surgery, but the immediate nursing action is to ensure the device is functioning properly by emptying it and recompressing to restore suction. This intervention directly reduces the risk of complications from inadequate drainage while allowing continued accurate monitoring of output. Simply documenting as expected does not address the need to keep the system therapeutic, and notifying the provider is typically reserved for concerning trends (e.g., rapidly increasing bright-red output, hemodynamic instability, or airway compromise).

Question 36

A 73-year-old patient with chronic atrial fibrillation develops sudden severe pain, pulselessness, pallor, and coolness in the right leg. The nurse should notify the health care provider and immediately?

Accepted Answer

Answer reason: This presentation reflects acute arterial occlusion (acute limb ischemia), a time-critical complication in atrial fibrillation due to embolization. Immediate nursing priorities are to prevent further compromise of arterial perfusion, minimize oxygen demand of the limb, and avoid actions that could dislodge or worsen the obstruction while urgent definitive treatment is arranged. Bedrest with the limb kept neutral supports perfusion assessment and avoids provoking pain or increasing metabolic demand. Elevation, compression, or exercise can further reduce arterial flow or increase tissue demand, accelerating ischemic injury.

Question 37

The nurse is caring for a patient who has been receiving warfarin (Coumadin) and digoxin (Lanoxin) as treatment for atrial fibrillation. Because the warfarin has been discontinued before surgery, the nurse should diligently assess the patient for which complication early in the postoperative period until the medication is resumed?

Accepted Answer

Answer reason: Warfarin is given in atrial fibrillation to prevent thrombus formation and systemic embolization, so stopping it temporarily increases the risk of thromboembolic events. Early postoperative hypercoagulability and relative immobility further raise the chance of clot formation while anticoagulation is held. Therefore, the nurse should closely monitor for new neurologic deficits suggestive of stroke and for acute respiratory symptoms consistent with pulmonary embolism. Excessive bleeding is less likely specifically because the anticoagulant has been discontinued preoperatively rather than continued.

Question 38

In teaching clients at risk for bradydysrhythmias, what information does the nurse include?

Accepted Answer

Answer reason: Bradydysrhythmias can be triggered or worsened by increased vagal tone, which slows SA/AV node conduction. Straining with bowel movements (Valsalva maneuver) increases intrathoracic pressure and vagal stimulation, potentially precipitating significant bradycardia, syncope, or heart block in at-risk clients. Teaching bowel regimen measures to avoid straining is a practical prevention strategy, especially in older adults or those with conduction disease. In contrast, avoiding potassium is not a general prevention measure for bradycardia, and nitroglycerin treats angina and can cause hypotension rather than correcting slow heart rate.

Question 39

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 depress protective airway reflexes, creating a high aspiration risk. The priority nursing action is to assess for the return of swallowing and gag reflexes before allowing oral intake or removing NPO restrictions. This directly prevents aspiration and subsequent respiratory compromise, which is a common post-procedure complication. Options like deep rapid breathing or early ambulation do not address the immediate airway protection priority and could be inappropriate if the client is still sedated.

Question 40

A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which of the following risks associated with placenta previa?

Accepted Answer

Answer reason: Postpartum, the client is at high risk for ongoing or delayed hemorrhage because the lower uterine segment contracts less effectively and placental implantation in that area predisposes to continued blood loss. Monitoring focuses on uterine tone, lochia amount, vital signs, and signs of hypovolemia to detect deterioration early. Chronic hypertension is more associated with placental abruption rather than previa, and while severe bleeding can lead to coagulopathy, the primary anticipated complication to monitor for is major bleeding.

Question 41

The clinic nurse is listening to voicemail messages in the office. Which client should the nurse call back first?

Accepted Answer

Answer reason: The timing (within the first weeks) and description (blistered lesions involving face/trunk) are red-flag findings that must be prioritized over expected or non-life-threatening side effects. By comparison, orthostatic dizziness with newly started carbidopa-levodopa is a common adverse effect that can often be managed with safety teaching and dose-timing adjustments. Eye burning from accidental capsaicin transfer and urinary hesitancy from hydroxyzine’s anticholinergic effects are concerning but typically less emergent than a suspected life-threatening drug reaction.

Question 42

The nurse has received report for a term newborn after a vaginal birth. Maternal history includes diagnosis of gestational diabetes at 25 weeks gestation and poorly controlled blood glucose during pregnancy. When assessing the newborn, which finding should the nurse most likely expect?

Accepted Answer

Answer reason: Chronic hypoxemia stimulates erythropoietin production, leading to polycythemia, which is reflected as an elevated hematocrit. This is a common expected assessment/lab finding in these newborns along with risks like hypoglycemia and hyperbilirubinemia. In contrast, delayed meconium passage is more classically associated with conditions like Hirschsprung disease or hypothyroidism rather than maternal diabetes. The fetal alcohol syndrome features listed (smooth philtrum, thin upper lip) are unrelated to gestational diabetes.

Question 43

The nurse in the ICU notes bleeding from the client's transparent dressing over her peripheral intravenous site, gum bleeding, and frank blood in the urine. The client was originally admitted for sepsis. What should be the nurse's immediate next action?

Accepted Answer

Answer reason: Active bleeding requires immediate measures to reduce blood loss using the least invasive, fastest intervention. Direct pressure at a peripheral IV site is an immediate nursing action that can promptly control external bleeding while the nurse continues assessment for systemic bleeding (e.g., possible DIC in sepsis). Laboratory evaluation such as hemoglobin/hematocrit may be indicated, but it does not stop ongoing blood loss and is not the first step. Notifying the provider is important once initial stabilization measures are underway and critical findings are communicated.

Question 44

Which client is at highest risk for development of pressure ulcers?

Accepted Answer

Answer reason: Pressure injuries are most strongly driven by immobility/unrelieved pressure plus poor tissue tolerance from malnutrition and decreased perfusion. Advanced age and low albumin indicate poor nutritional reserves and impaired wound healing, while being thin reduces natural padding over bony prominences. Confusion increases risk because the client may not perceive discomfort, may not reposition, and may be unable to follow turning/skin-protection instructions. By comparison, bed rest after MI increases risk, but it lacks the additional high-risk factors of severe malnutrition and cognitive impairment present here.

Question 45

Packed red blood cells have been prescribed for a female client with a hemoglobin level of 7.6g/dL (76mmol/L) and a hematocrit level of 30% (0.30). The nurse takes the client's temperature before hanging the blood transfusion and records 100.6°F (38.1°C) orally. Which action should the nurse take?

Accepted Answer

Answer reason: A key transfusion safety principle is to obtain and evaluate baseline vital signs; a preexisting fever can indicate active infection or another process and would make it difficult to distinguish a new febrile hemolytic/nonhemolytic transfusion reaction once blood is started. With an oral temperature of 38.1°C, the safest nursing action is to hold the blood and report the finding so the prescriber can determine whether to postpone transfusion and/or evaluate and treat the fever first. Giving acetaminophen or an antihistamine to proceed can mask early reaction signs and delays recognition of potentially life-threatening complications. Although the client is anemic, transfusion urgency does not override the need to clarify an abnormal baseline assessment that increases risk during administration.

Question 46

The nurse is caring for a child diagnosed with Reye’s syndrome. The nurse monitors for manifestations of which condition associated with this syndrome?

Accepted Answer

Answer reason: Cerebral edema leads to rising intracranial pressure, so the nurse must closely monitor for changes in level of consciousness, vomiting, seizures, and abnormal posturing. This directly reflects the syndrome’s hallmark risk of rapid neurologic compromise rather than a renal manifestation. Hyperglycemia is not the classic expected finding; hypoglycemia is more likely with severe liver dysfunction in children.

Question 47

The nurse is reviewing the labs of a child who has recently had oral surgery. Which of the following lab results should the nurse pay the closest attention to?

Accepted Answer

Answer reason: Postoperative oral surgery patients are at meaningful risk for bleeding because the mouth is highly vascular and clots can be disrupted by speaking, suctioning, or chewing. A prolonged coagulation study signals impaired hemostasis and predicts postoperative hemorrhage, which is the most immediate safety threat among the listed labs. Monitoring coagulation also guides whether additional evaluation or interventions (e.g., reviewing anticoagulant exposure, liver function, vitamin K status) are needed. BUN and creatinine relate to renal function and medication clearance but are less directly tied to acute post-op oral bleeding risk, and viral load does not address an immediate postoperative complication in this context.

Question 48

The nurse is obtaining a urine sample from a client with an indwelling Foley catheter. To prevent bladder distention and possible subsequent hydronephrosis, what action should the nurse take?

Accepted Answer

Answer reason: Maintaining continuous, unobstructed urinary drainage is the key principle to prevent urine backflow, bladder overdistention, and upstream pressure that can contribute to hydronephrosis. Clamping is used briefly only to allow fresh urine to collect in the tubing for a sterile specimen. Once enough urine is obtained, the clamp must be released right away to re-establish free drainage and minimize urinary retention. Prolonged or unnecessary clamping is the main unsafe step in this process, whereas needle size or insertion angle does not address the complication of obstruction.

Question 49

A client who has had a brain attack (stroke) is being managed on the medical nursing unit. At 8:00 AM, the client was awake and alert with vital signs of temperature 98° F orally, pulse 80 beats/min, respirations 18 breaths/min, and blood pressure 138/80 mm Hg. At noon, the client is now confused and arousable only to tactile stimuli, and vital signs are temperature 99° F orally, pulse 62 beats/min, respirations 20 breaths/min, and blood pressure 166/72 mm Hg. The nurse should take which action?

Accepted Answer

Answer reason: A sudden decline in level of consciousness with a rising blood pressure and relative bradycardia after a stroke suggests neurologic deterioration and possible increased intracranial pressure or hemorrhagic conversion, which is a time-sensitive complication. This change is not an expected finding and requires urgent provider notification for rapid evaluation and potential imaging/therapy. Retaking vital signs may confirm numbers but must not delay escalation when there is a clear acute change in neurologic status. Reorientation is inappropriate for a markedly decreased responsiveness, and giving PRN antihypertensive could reduce cerebral perfusion without a specific order/parameters in the context of evolving neurologic injury.

Question 50

The healthcare provider is assisting during the insertion of a pulmonary artery catheter. Which of these, if assessed in the patient, would indicate the patient is experiencing a complication from the catheter insertion?

Accepted Answer

Answer reason: Rising intrathoracic pressure shifts mediastinal structures, producing tracheal deviation away from the affected side—an acute, life-threatening complication needing immediate intervention. The other findings listed are compatible with normal respiratory assessment (vesicular sounds, typical I:E pattern) or a nonspecific/near-normal excursion value and do not specifically indicate catheter-related thoracic injury. Tracheal deviation is therefore the most concerning assessment suggesting a procedure complication.

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