Question 1

Which of the following nursing intervention takes priority in a patient who has undergone corrective surgery for laceration of the bladder?

Accepted Answer

Answer reason: Immediate post-operative care prioritizes patient safety because anesthesia, opioids, and pain can cause dizziness, weakness, and impaired judgment, increasing fall risk. Implementing fall-prevention measures is an urgent, universal intervention that protects the patient from avoidable injury while other comfort and mobility measures can follow once safety is ensured. The other options help prevent complications like pressure injury or venous stasis but are not as immediately critical as preventing a fall in the early recovery period.
Category reason: This question asks for a priority nursing intervention focused on preventing immediate postoperative harm, which aligns with NCLEX patient safety and accident prevention.

Question 2

A nurse finds a client post-fall on the floor who is conscious but bleeding from the scalp. What is the immediate nursing action?

Accepted Answer

Answer reason: A. Apply pressure to the wound Active scalp bleeding should be controlled immediately because scalp lacerations can bleed heavily and rapid hemostasis helps prevent hypovolemia and worsening shock risk. Applying direct pressure is a first-aid priority before secondary assessments and notifications. After bleeding control, the nurse should proceed with vital signs and focused neurologic assessment for possible head injury, then escalate care as indicated.
Category reason: This is a patient-care priority question after a fall, focusing on immediate safety-focused nursing intervention to prevent complications from injury, which aligns with Accident-Error Prevention.

Question 3

The nurse observes the client, who has a history of aggressive behavior toward others, swearing and kicking the furniture in the dayroom. Based on the client's behavior, what should be the nurse's priority?

Accepted Answer

Answer reason: D. Provide for a safe, therapeutic milieu. Safety is the immediate priority when a client with a known history of aggression shows escalating, potentially violent behavior in a public area. The nurse should first act to protect the client, other clients, and staff by reducing environmental risk (e.g., increasing supervision, moving others away, ensuring access to help, and removing potential weapons) and maintaining a controlled therapeutic setting. De-escalation is important, but it is implemented within the framework of ensuring the environment is safe and that harm is prevented. Trying to identify or eliminate the source of agitation can be unreliable in the moment and should not delay immediate safety measures, while assessment continues concurrently as safety is secured.

Question 4

The nurse prepares to administer an IV antibiotic to a 3-year-old child and notices the identification band has been taped to the foot of the toddler's bed. Prior to administering the medication it is MOST important for the nurse to take which action?

Accepted Answer

Answer reason: Medication safety requires using two reliable patient identifiers, and the wrist/ankle ID band is the primary source for correct patient identification. A band taped to the bed is not attached to the patient and can be mixed up between patients, creating a high risk for wrong-patient medication administration. The nurse should ensure the child is wearing the ID band and then verify the information on it before giving an IV antibiotic. Parent report and the bedside flow sheet are secondary sources and cannot replace direct verification with the patient’s identification band; a 3-year-old may also be an unreliable source for full identification.

Question 5

What is the maximum suction time for a patient with a tracheostomy?

Accepted Answer

Answer reason: The standard nursing guideline is to limit each suction pass to about 10 seconds (often cited as 10–15 seconds) with re-oxygenation between passes as needed. This time limit balances secretion removal with preserving oxygenation and hemodynamic stability. Longer durations such as 30 seconds or 1 minute markedly increase risk of desaturation and dysrhythmias, while 5 seconds may be unnecessarily short if secretions are thick and a safe standard maximum is being asked.

Question 6

While Sarah is in severe pain, you left her alone with the side rails down, and the bed in a high position. She then falls and developed bleeding. What law has been broken?

Accepted Answer

Answer reason:  Nurses have a duty to maintain a safe environment and prevent foreseeable harm, especially for a patient in severe pain who is at increased risk of falling. Leaving the bed in a high position with side rails down violates basic fall-prevention safety measures and represents a breach of the standard of care. The resulting fall and bleeding demonstrate causation and harm linked to that breach, fulfilling the elements of negligence. Assault and battery involve intentional threats or unwanted touching, which are not described here. This is a type of civil wrongdoing, but the most specific legal concept tested by the scenario is negligent care.

Question 7

MEASURE URINE OUTPUT AT

Accepted Answer

Answer reason: Viewing the fluid level at the same height as the measurement markings minimizes over- or underestimation that occurs when the container is read from above or below. This accuracy is clinically important because urine output trends are used to assess perfusion and kidney function and guide timely interventions. Options suggesting above or below eye level increase the risk of systematic measurement error and unsafe clinical decisions.

Question 8

Which of the following nursing outcomes is most appropriate during the crisis stage of caring for a victim of domestic violence?

Accepted Answer

Answer reason: Ensuring protection from further violence and addressing urgent medical needs follows the fundamental priority framework of airway/breathing/circulation and safety before longer-term planning. Options involving shelters, safety planning, legal action, and discharge resources are important but are more appropriate once the immediate crisis is controlled and the client is medically stable. Selecting a short-term, measurable outcome focused on safety and treatment aligns with urgent risk reduction and crisis intervention goals.

Question 9

Which practice will help to reduce the risk of a needlestick injury?

Accepted Answer

Answer reason: Having the sharps container close by reduces the time a used needle is in hand and prevents walking around with an exposed sharp, both common causes of injuries. It also supports safe workflow by avoiding interruptions or unsafe “temporary placement” of sharps on surfaces. Recapping used needles and hand-to-hand passing increase exposure time and risk of accidental puncture, so they are avoided except in rare, controlled situations.

Question 10

Which of the following is an organizational factor that affects workplace violence directed at nurses?

Accepted Answer

Answer reason: Inadequate staffing leads to delayed responses to patient needs, higher stress and fatigue among nurses, and fewer team members available to intervene early, all of which are well-established contributors to agitation and assaults. Measures like security guards or restricted areas are generally protective controls rather than risk-enhancing organizational drivers. Short hospital stays describe a client characteristic/throughput issue and are less directly tied to the facility’s internal staffing and safety infrastructure than staffing levels.

Question 11

The patient is to receive oral guaifenesin (Mucinex) twice a day. Today, the nurse was busy and gave due medication 2 hours after the scheduled dose was due. What type of problem does this represent?

Accepted Answer

Answer reason: Administering a scheduled medication 2 hours late is a timing deviation and can alter therapeutic effect and symptom control, especially for time-sensitive drugs. The medication, dose, and route were not described as incorrect, so those rights are not the primary issue. This situation is best categorized as a medication administration timing error, requiring documentation and monitoring for impact.

Question 12

The nurse is caring for a 72-year-old client taking gabapentin (Neurontin) for a seizure disorder. Because of this client's age, the nurse would establish which nursing diagnosis related to the drug's common adverse effects?

Accepted Answer

Answer reason: A nursing diagnosis focused on preventing injury is therefore the safest and most clinically relevant priority for a 72-year-old starting or taking this medication. Monitoring gait/steadiness, advising slow position changes, and implementing fall precautions align with this risk. Constipation can occur but is not as central or immediately dangerous as medication-related gait instability in the elderly. This diagnosis best reflects the common adverse-effect profile and age-related vulnerability.

Question 13

A client with meningitis has a history of seizures. What activity should the nurse do while the client is actively seizing?

Accepted Answer

Answer reason: During an active seizure, the nursing priority is airway protection and prevention of aspiration and injury. Side-lying positioning promotes drainage of saliva/emesis and helps maintain a patent airway without inserting objects into the mouth. Restraining the patient increases the risk of musculoskeletal injury and does not stop seizure activity. Suctioning is not performed routinely during the convulsion because it can be unsafe and should be done only when the seizure stops and the airway can be accessed safely.

Question 14

A client is diagnosed with a brain tumor. As the nurse assesses the client from the bed to the chair, the client begins to have a generalized seizure. Which action should the nurse take first?

Accepted Answer

Answer reason: Guiding the client safely to the floor reduces fall trauma and placing them side-lying promotes drainage of secretions and helps maintain a patent airway. Objects should never be inserted into the mouth because this can cause dental injury, aspiration, or obstruct the airway. Documentation and timing are important but are secondary to immediate safety actions, and a code response is not the first step unless the client progresses to respiratory arrest or status epilepticus.

Question 15

An appropriate nursing diagnosis for a patient who has an acute attack of vertigo, nausea, and hypertension, ringing of the ears is?

Accepted Answer

Answer reason: The highest-priority nursing diagnosis focuses on immediate safety because dizziness markedly increases fall risk, especially during position changes or ambulation. This diagnosis directly drives preventive interventions such as assisted ambulation, fall precautions, and environmental safety measures. Other options are less urgent or less directly supported by the data provided (e.g., communication issues are not the primary immediate threat).

Question 16

A hospitalized client with impaired vision must get a picture in his or her mind of the hospital room and its content in order to mobilize independently and safely. What must the nurse do to monitor in the client's room?

Accepted Answer

Answer reason: Keeping furniture in a fixed arrangement minimizes unexpected obstacles and reduces risk for trips and falls during ambulation and transfers. While removing clutter is important, controlling every small item placement (like slippers or visitor items) is less reliable and does not address major hazards that change walking paths. Placing a commode at the bedside may help toileting access but does not provide global fall-risk reduction if the room layout changes.

Question 17

When planning discharge teaching for a young adult, the nurse should include the potential health problems common in this age group. What should the nurse include in this teaching plan?

Accepted Answer

Answer reason: This includes counseling on motor vehicle safety, substance-impaired driving, workplace hazards, and risk-taking behaviors. The other options are more characteristic of older-adult health risks (e.g., glaucoma and cardiovascular disease prevalence rising with age) and are less central as “common” problems for the typical young adult. Framing discharge education around modifiable behaviors and injury prevention aligns with primary prevention goals for this age group.

Question 18

Scenario: A 22-year-old patient is admitted to the psychiatric unit with a diagnosis of schizophrenia. The patient appears to be responding to internal stimuli and reports auditory hallucinations telling him to harm himself. Question: As a nurse, what is your initial intervention for this patient?

Accepted Answer

Answer reason:  Command hallucinations with self-harm content indicate imminent suicide risk, so the first nursing priority is immediate safety. Continuous 1:1 observation provides rapid detection and interruption of self-injurious behavior while further assessment and treatment are initiated. Medications may reduce psychosis, but they do not act instantly and should not replace immediate safety measures in an acutely unsafe patient. Detailed exploration of hallucinations or group therapy can be appropriate later, but they are not the initial action when there is a credible risk of self-harm.

Question 19

A nurse is instructing a class for new parents at a local community center. The nurse would stress that which activity is most hazardous for an 8 month-old child?

Accepted Answer

Answer reason:  Aspiration and choking prevention is a top safety priority for infants, whose airway diameter is small and protective chewing/swallowing skills are immature. Whole nuts are classic high-risk choking hazards because they are hard, irregularly shaped, and can obstruct the airway or be aspirated into the bronchi. In contrast, riding in a car is safe when properly restrained in an age-appropriate rear-facing car seat, and while falls and electrical outlets are important hazards, they are typically mitigated with supervision and environmental safeguards. The option that represents the most immediate life-threatening risk specific to this age group is choking from nuts.

Question 20

Which type of accidental poisoning would the nurse expect to occur in children under age 6?

Accepted Answer

Answer reason: Their smaller body mass also makes even small ingested amounts clinically significant, which is why prevention focuses on child-resistant packaging and safe storage. In contrast, inhalation exposures are more typical with fumes in poorly ventilated areas and are less characteristic as the primary accidental route in toddlers. Topical and ocular exposures occur but are generally less frequent than ingestion as an overall poisoning mechanism in children under 6.

Question 21

An 8 year-old client is admitted to the hospital for surgery. The child's parent reports the following allergies. Of these allergies which one should all health care personnel be aware of?

Accepted Answer

Answer reason: Balloons are a classic latex-containing item and signal the need for latex-free precautions across all departments (OR, anesthesia, nursing, environmental services). In surgical settings, preventing exposure is time-critical because reactions can occur during anesthesia when early symptoms may be masked. By contrast, allergies like molds or perfumed soap are less likely to cause sudden life-threatening reactions from ubiquitous equipment contact during procedures.

Question 22

The nurse enters the room as a 3 year-old is having a generalized seizure. Which intervention should the nurse do first?

Accepted Answer

Answer reason: Removing nearby hard or sharp objects reduces the risk of head trauma and fractures during uncontrolled movements and can be done instantly without manipulating the child. Side-lying is appropriate to support airway drainage, but repositioning may be less immediate or feasible depending on violent tonic-clonic activity, and should follow basic environmental safety measures. Restraining increases injury risk and can worsen agitation, and anticonvulsants are typically given after initial safety/airway actions or if the seizure is prolonged per protocol.

Question 23

A nurse is stuck in the hand by an exposed needle. What immediate action should the nurse take?

Accepted Answer

Answer reason: Thoroughly washing the puncture site with soap and water right away is the fastest, most effective first step and can be performed before any reporting or follow-up. Subsequent actions like notifying the supervisor/risk management and contacting employee health are important for documentation, source testing, and prophylaxis decisions, but they are not the first action. Looking up policy delays essential first aid and does not address the exposure in the moment.

Question 24

The nurse's primary intervention for a client who is experiencing a panic attack is to?

Accepted Answer

Answer reason: The nurse’s first priority is to ensure the environment is safe and provide calm, simple, directive support to reduce escalating distress. Establishing a therapeutic relationship and exploring the experience are important but are not the initial priority during acute panic when the client may be unable to process complex communication. Teaching self-control strategies is better suited after the acute episode resolves, when learning and retention are more likely.

Question 25

A priority goal of involuntary hospitalization of the severely mentally ill client is?

Accepted Answer

Answer reason: The most urgent nursing and legal priority is to reduce danger through close observation, restricting access to means, and initiating emergency stabilization. Symptom reduction and improved functioning are important but are longer-term outcomes that follow once safety is established. Re-orientation may be helpful for some clients, but it does not address the immediate rationale for involuntary commitment when there is risk of harm.

Question 26

A client is receiving Total Parenteral Nutrition (TPN) via Hickman catheter. The catheter accidentally becomes dislodged from the site. Which action by the nurse should take priority?

Accepted Answer

Answer reason: Applying firm pressure/pressure dressing helps achieve hemostasis and occludes the tract, reducing the chance of air embolism while additional help is obtained. Assessments like respiratory status or mental status are important but come after the immediate life-threatening risk at the open central line site is addressed. Checking catheter tip integrity is secondary once the patient is stabilized and the site is secured.

Question 27

The client with multiple sclerosis has an order to change the nasogastric tube. To promote safety when removing the tube, the nurse should?

Accepted Answer

Answer reason: This is a direct, immediate safety measure during the removal step itself, which is particularly important in neuromuscular disease where swallowing/cough effectiveness may be impaired. Offering water is more relevant for comfort after removal and could increase aspiration risk if swallowing is weak. A code cart is not routinely required for planned NG tube changes, and draining the tube does not meaningfully address airway protection during removal.

Question 28

Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls?

Accepted Answer

Answer reason: Decreased vision directly increases misjudging distances, tripping over obstacles, and missing environmental cues (uneven flooring, cords, poor lighting), making it a high-probability and immediate fall hazard. Fatigue-related mobility changes can increase risk, but it is often intermittent and may be mitigated with rest and pacing more readily than sensory loss. Nocturia increases nighttime toileting and can contribute to falls, but the core precipitating factor is usually environment/urgency rather than a constant sensory deficit affecting all mobility. Impaired gas exchange is serious clinically, yet it is not as directly or consistently linked to mechanical falls as visual impairment in an elderly client.

Question 29

The nurse is planning discharge for a 90 year-old client with musculo-skeletal weakness. Which intervention should be included in the plan and would be most effective for the prevention of falls?

Accepted Answer

Answer reason: Older adults commonly fall in the bathroom due to wet surfaces, tight spaces, and frequent sit-to-stand movements from the toilet and tub. Grab bars directly reduce fall risk by improving stability and allowing controlled weight shifting despite musculoskeletal weakness. Nightlights and eyeglasses can help address visibility, but they do not provide physical support at the moment of imbalance. Strengthening exercises are beneficial long term, but they are not as immediately protective in the home environment as structural safety modifications.

Question 30

An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml The correct action is to?

Accepted Answer

Answer reason: A 2.0 mL IM dose is generally too large for a single injection site in a 2-year-old, so dividing the dose into two injections keeps each site within safe volume limits. Using the dorsogluteal site increases risk of sciatic nerve injury and is not preferred in young children. Requesting a smaller ordered volume does not address the immediate safe administration of the prescribed total dose, and switching formulations is not an equivalent route without a new order.

Question 31

The nurse is reassigned to work at the Poison Control Center telephone hotline. In which of these cases of childhood poisoning would the nurse suggest that parents have the child drink orange juice?

Accepted Answer

Answer reason: Philodendron contains insoluble calcium oxalate crystals that cause immediate oral burning and irritation rather than deep systemic toxicity. Giving a cold acidic drink like orange juice (or other fluids) can help soothe the mouth and encourage swallowing/dilution after small ingestions, while monitoring for drooling or airway symptoms. In contrast, caustic alkalis such as crystal drain cleaner should not be given acidic fluids because neutralization can worsen tissue injury and vomiting increases re-exposure. Hydrocarbons (lighter fluid) pose aspiration risk where oral fluids are generally avoided, and benzodiazepine overdose requires assessment/EMS guidance rather than home fluids.

Question 32

The nurse is caring for a client who requires a mechanical ventilator for breathing. The high pressure alarm goes off on the ventilator. What is the first action the nurse should perform?

Accepted Answer

Answer reason: A high-pressure alarm can reflect patient problems (e.g., coughing, biting the tube, secretions, bronchospasm) or circuit obstruction/kinking, and the immediate priority is to determine whether ventilation/oxygenation is compromised. A rapid check of respiratory effort, SpO2, breath sounds, chest rise, and tube/circuit patency guides the correct next intervention. Immediately bagging is indicated if the patient is in distress or ventilation is clearly failing, but it is not automatically the first step when the alarm sounds. Resetting the alarm or calling RT delays identification and correction of a potentially life-threatening problem.

Question 33

When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse's best action is to?

Accepted Answer

Answer reason: Escalating the mismatch to admissions initiates correction through the official registration workflow and prevents downstream errors (medication, tests, procedures, transfusions). Applying a mismatched band, even temporarily, creates an immediate risk of wrong-patient care. Altering documents or independently creating a new band bypasses controlled verification steps and increases the chance of propagating incorrect demographics.

Question 34

Which bed position is preferred for use with a client in an extended care facility on falls risk prevention protocol?

Accepted Answer

Answer reason: Locking the wheels and keeping the bed in the lowest position decreases the chance of a high-impact fall during transfers or attempts to get up. Placing the bed against a wall reduces exposed edges and can provide a stable boundary that helps limit rolling/falling out of bed. A common unsafe distractor is raising all four side rails, which can function as a restraint and increase injury risk if the client tries to climb over.

Question 35

A school-aged child has had a long leg (hip to ankle) synthetic cast applied 4 hours ago. Which statement from the mother indicates that teaching has been inadequate?

Accepted Answer

Answer reason: " Cast care teaching emphasizes preventing skin injury and maintaining circulation; itching should be managed by keeping the cast dry, using prescribed antipruritics, or gently blowing cool air from a hair dryer on a cool setting rather than applying cold packs. Placing an ice pack over a newly applied cast can introduce moisture and temperature extremes that may compromise the cast material and increase risk of skin breakdown or pressure injury, especially while swelling is evolving. In contrast, keeping a synthetic cast uncovered initially allows heat to dissipate during early curing, and elevating the extremity on pillows helps limit edema. Weight-bearing restrictions depend on provider instructions and cast type, so that statement is not as clearly unsafe as using an ice pack for itching.

Question 36

The nurse knows that which statement by the mother indicates that the mother understands safety precautions with her four month-old infant and her 4 year-old child?

Accepted Answer

Answer reason: The core safety principle is to reduce risk of falls, suffocation/airway obstruction, and unsafe handling by older children while maintaining close supervision. Placing a 4-month-old on a flat surface on the floor minimizes fall risk compared with elevated surfaces and avoids unsafe sleep positions that can compromise the airway. By contrast, having the 4-year-old hold/feed the infant introduces a significant drop/aspiration hazard, and putting a rear-facing car seat in the front seat exposes the infant to potentially fatal airbag injury. The statement also implies a safer interaction where the infant is positioned in a stable environment rather than on a sofa or in an unsafe posture.

Question 37

A 4 year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first?

Accepted Answer

Answer reason: Clearing hard objects near the child reduces the risk of head trauma, fractures, and lacerations while seizure activity is ongoing. Moving the child to a bed can be unsafe during convulsions and should be done only if it can be performed safely; otherwise, protect the child where they are. Putting anything in the mouth is contraindicated because it can cause dental injury, aspiration, or airway obstruction. IV anticonvulsants are administered per protocol when indicated, but immediate hazard removal is the fastest, safest initial nursing action.

Question 38

Which action is most likely to ensure the safety of the nurse while making a home visit?

Accepted Answer

Answer reason: Maintaining vigilance and exiting promptly if environmental or behavioral cues raise concern directly reduces exposure time to potential violence and is within the nurse’s control during the encounter. Checking a record for prior violence and carrying a phone are useful preventive supports, but they do not replace real-time judgment when conditions change. Lack of visible weapons is not a reliable indicator of safety, since threats may still be present without obvious objects.

Question 39

You are caring for an elderly woman with macular degeneration who is legally blind. You visit her in her home to assess her needs. Which of the following represents a risk for falls?

Accepted Answer

Answer reason: Loose or unsecured rugs can slide or bunch, creating an uneven surface that is difficult to detect with limited vision and can precipitate a trip-and-fall. In contrast, a non-skid tub surface, a clutter-free floor, and secure railings are protective environmental modifications that decrease fall risk. Home safety assessments commonly recommend removing throw/scatter rugs or securing them with non-slip backing/tape.

Question 40

The nurse in the emergency department is observing a staff member caring for a client who is experiencing an acute hemorrhagic stroke. The nurse should intervene if the staff member is observed?

Accepted Answer

Answer reason: Heparin is specifically contraindicated in active intracranial hemorrhage unless a compelling, specialist-directed indication exists, so this action requires immediate nursing intervention to prevent harm. Keeping the client NPO is appropriate due to high aspiration risk until a swallow evaluation is completed. Mechanical VTE prophylaxis (e.g., sequential compression devices) is typically appropriate when pharmacologic anticoagulation is unsafe, and cautious blood pressure control with IV antihypertensives may be ordered to reduce ongoing bleeding risk.

Question 41

An older adult client has new onset atrial fibrillation. The nurse prioritizes which nursing diagnosis as the highest priority for the client?

Accepted Answer

Answer reason: Immediate nursing priority follows ABCs and safety: preventing falls/trauma from syncope is a direct, imminent threat to life and function. While decreased cardiac output may lead to fatigue and activity intolerance, that problem is typically secondary to stabilizing hemodynamics and preventing injury during acute onset. Anxiety and urinary issues do not pose the same immediate safety risk as potential loss of consciousness and falls.

Question 42

The nurse accidentally pierced her finger with needlestick after giving Lovenox to a patient with acute DVT. What should the nurse do during needlestick injury? Arrange in order. 1. Notify the supervisor. 2. Handwashing. 3. Assess patient and nurse (herself). 4. Take prophylactic management.?

Accepted Answer

Answer reason: Next, the exposure must be assessed to determine the level of risk, including the type of device, depth of injury, and the source patient’s blood-borne pathogen status, along with the nurse’s baseline labs and immunization status. After immediate safety actions and initial assessment, the event is reported through the proper chain of command to trigger institutional exposure protocols and documentation. Finally, indicated post-exposure prophylaxis is started as soon as possible based on risk stratification and test results/time sensitivity (e.g., HIV PEP ideally within hours, HBV measures depending on vaccination/antibody status).

Question 43

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

Accepted Answer

Answer reason: Thrombocytopenia increases bleeding risk because platelets are essential for primary hemostasis and clot formation. A platelet count of 80,000/µL is below normal and warrants teaching to prevent mucosal and internal bleeding (e.g., avoid aspirin/NSAIDs, use soft toothbrush/electric razor, report petechiae/black stools, avoid trauma and invasive procedures unless necessary). These measures directly reduce the likelihood of hemorrhage complications, which is the key safety threat in autoimmune thrombocytopenic purpura. Fall prevention is generally helpful but is less targeted than broad bleeding-precaution education for a platelet disorder. Oxygen therapy and energy conservation do not address the primary complication of thrombocytopenia.

Question 44

The nurse is caring for a 3-month-old female in the post-operative period following repair of a bilateral cleft lip. The nurse is aware that which of the following interventions must be implemented in the post-operative period?

Accepted Answer

Answer reason: The core principle after cleft lip repair is protecting the surgical site from tension, rubbing, and self-inflicted trauma that can cause bleeding, wound dehiscence, and impaired healing. Soft elbow immobilizers reduce the infant’s ability to flex the arms and touch or scratch the lip incision while still allowing shoulder movement and comfort. Feeding choices vary by surgeon protocol (some allow special nipples; others prefer syringe/spoon), so they are not the single “must” intervention across settings. Prone positioning is not routinely required and can introduce additional risks; the consistent priority is incision protection.

Question 45

A nurse is caring for a neonate born to a diabetic mother who begins experiencing generalized jerky movements. What is the nurse's initial action?

Accepted Answer

Answer reason: Immediate nursing priority with suspected neonatal seizure activity is airway protection and prevention of aspiration or injury. Side-lying positioning helps maintain a patent airway and allows secretions to drain, reducing aspiration risk during jerky movements. Checking glucose is important because infants of diabetic mothers are at high risk for hypoglycemia, but assessment and treatment should follow rapid stabilization of breathing and safety. Calling the provider is appropriate after initial stabilization and focused assessment; rectal dextrose is not a standard, safe route for treating neonatal hypoglycemia.

Question 46

A client who sits in a chair begins to have a generalized tonic-clonic seizure. Place the interventions in order of priority. 1. Position client on side. 2. Administer prescribed antiepileptic medication. 3. Ease the client to the floor. 4. Push aside any furniture.?

Accepted Answer

Answer reason: Because the client is in a chair, first guiding them safely to the floor reduces risk of falling and head/neck trauma. Next, clearing nearby furniture prevents impact injuries during uncontrolled movements. Once on the floor, turning to the side supports drainage of secretions/vomitus and reduces aspiration risk; medications are addressed after immediate safety/airway measures, and are typically given once access and orders are verified and the situation is controlled.

Question 47

The acute care clinic nurse administers a prescribed narcotic to a client with renal colic and then discharges the client without ensuring that the client has a designated driver. The client is subsequently involved in a motor vehicle accident causing injury to self and others. Which ethical principle did the nurse violate?

Accepted Answer

Answer reason: Administering an opioid can impair alertness and reaction time, so discharging a patient without confirming safe transportation creates a predictable risk of injury. The resulting motor vehicle accident reflects a preventable safety hazard linked to the nurse’s omission in discharge safety planning. Autonomy concerns respecting a patient’s choices, veracity involves truth-telling, and paternalism is overriding patient choice “for their own good,” none of which is the central ethical failure here.

Question 48

What is the most serious consequence of propping an infant's bottle?

Accepted Answer

Answer reason: Bottle propping allows continuous flow of milk/formula even when the infant is not coordinating suck-swallow-breathe effectively, increasing the risk of airway obstruction and aspiration into the lungs. Aspiration is immediately life-threatening and can lead to acute respiratory distress and later aspiration pneumonia. While ear infections and dental caries are recognized longer-term risks of bottle propping, they are not as urgent or dangerous as airway compromise. Colic is nonspecific and not the most serious hazard compared with preventable aspiration events.

Question 49

A nurse is instructing students about seizures in pediatric patients. He explains that seizures are categorized as generalized or partial and explains each. In talking about how to react when a child has a seizure which of the following statements would be included?

Accepted Answer

Answer reason: During an active seizure, the priority is injury prevention and maintaining airway safety without inserting objects into the mouth. Placing a tongue blade (or any object) can break teeth, lacerate oral tissues, and obstruct the airway or be aspirated, worsening harm. The appropriate approach is to protect the head, remove nearby hazards, and position the child on the side when possible to promote drainage and reduce aspiration risk. Restraining a seizing child is unsafe because it increases the risk of musculoskeletal injury and does not stop the seizure.

Question 50

A patient with atrial fibrillation is ambulating and suddenly says, “I feel really dizzy.” What should the nurse do?

Accepted Answer

Answer reason: Assisting the patient to sit down reduces orthostatic stress and prevents injury if syncope occurs. After the patient is safe, the nurse can rapidly assess hemodynamic stability (e.g., blood pressure, pulse/rhythm) and escalate care if hypotension or rapid ventricular response is present. Choosing assessment first delays the most time-sensitive intervention—preventing a fall and associated harm.

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