Question 1

The nurse is planning care for a client with Huntington disease. Which of the following interventions should the nurse include in the client’s plan of care?

Accepted Answer

Answer reason: Huntington disease is a progressive neurodegenerative disorder that commonly causes cognitive decline and impaired executive function along with choreiform movements. Providing structured environmental cues and external memory aids supports orientation and reduces confusion-related agitation, improving safety and daily functioning. In contrast, restricting out-of-bed activity promotes deconditioning and does not address the need to maintain mobility with safety measures. Clients often have increased caloric needs and unintended weight loss, so limiting snacks is inappropriate, and aspiration risk is better reduced with individualized swallow evaluation and texture modification rather than automatically using a full liquid diet.

Question 2

A nurse prepares a care plan for a client with ascites related to cirrhosis. Which nursing diagnosis takes priority?

Accepted Answer

Answer reason: With ascites, increased intra-abdominal pressure elevates the diaphragm, reduces lung expansion, and can cause dyspnea and decreased oxygenation, making respiratory status the most urgent problem to address. Managing breathing supports immediate oxygen delivery while other problems are treated. Excess fluid volume is important but is primarily a contributing factor to the respiratory compromise rather than the most time-critical diagnosis in the moment. Risk for anemia and nutritional deficiency are less immediate threats compared with compromised ventilation.

Question 3

The nurse is caring for a client who sustained a cervical spinal cord injury. Which priority vital sign should the nurse obtain?

Accepted Answer

Answer reason: Airway and breathing take priority in ABCs because hypoventilation and impending respiratory failure can occur quickly and may be clinically subtle at first. Measuring respiratory rate provides immediate information about ventilatory adequacy and need for urgent airway/ventilatory support. Blood pressure and pulse are also important (e.g., neurogenic shock), but oxygenation/ventilation failure is the most immediately life-threatening early complication to detect and address.

Question 4

Which symptom of pneumonia may present differently in the older adult pt than in the younger adult pt?

Accepted Answer

Answer reason: This makes fever a less reliable indicator in geriatrics compared with younger adults, where fever is more common and pronounced. In contrast, abnormal lung sounds such as crackles can still be present across age groups and are not classically described as “different” in presentation by age. Because missed fever can delay recognition, nurses should also watch for atypical signs in older adults such as acute confusion, functional decline, or tachypnea/hypoxia.

Question 5

The physician orders the administration of high-humidity oxygen by face mask and placement of the patient in a high Fowler’s position. After assessing Mrs. Paul, the nurse writes the following nursing diagnosis: Impaired gas exchange related to increased secretions. Which of the following nursing interventions has the greatest potential for improving this situation?

Accepted Answer

Answer reason: Chest physiotherapy (including percussion, vibration, postural drainage) directly loosens and moves retained secretions toward the central airways where they can be expectorated or suctioned, reducing obstruction and shunting. Increasing oral fluids and adding room humidification can help thin secretions, but they act more indirectly and may be limited by patient tolerance or contraindications (e.g., fluid restriction). Continuing humidified oxygen supports oxygenation but does not address the underlying secretion retention, so it is less effective than actively clearing the airway.

Question 6

The nurse is assessing a client with congestive heart failure. Which physical assessment finding should the nurse expect?

Accepted Answer

Answer reason: Heart failure leads to volume overload and elevated ventricular filling pressures, producing a low-frequency extra heart sound in early diastole. This finding reflects decreased ventricular compliance/dilation from fluid overload and is a classic assessment clue in congestive heart failure. Intermittent claudication points to peripheral arterial disease rather than pump failure. Venous stasis ulcers are a manifestation of chronic venous insufficiency, not a primary expected cardiac auscultation finding in heart failure. Widened pulse pressure is more typical of conditions like aortic regurgitation or high-output states, whereas heart failure often shows narrowed pulse pressure from reduced stroke volume.

Question 7

The nurse is caring for a 76-year-old client with pneumonia. What is the priority nursing assessment?

Accepted Answer

Answer reason: Airway assessment is the first priority in acute respiratory conditions because a compromised airway can rapidly lead to hypoxia and respiratory arrest. Pneumonia can increase secretions, cause decreased cough effectiveness (especially in older adults), and lead to obstruction, so confirming a clear airway drives all subsequent interventions. Respiratory rate and auscultation/percussion provide important data about ventilation and consolidation, but they are secondary if the airway is not open. In practice, ensuring airway patency also guides immediate actions such as positioning, suctioning, and escalation of care when obstruction is suspected.

Question 8

Which of the following symptoms is most concerning in a patient with pneumonia?

Accepted Answer

Answer reason: This finding indicates the patient may not be ventilating/oxygenating adequately due to alveolar inflammation and consolidation. It requires immediate assessment of oxygen saturation, work of breathing, mental status, and prompt interventions such as supplemental oxygen and escalation of care if worsening. Cough and fever are common expected manifestations of infection, and chest pain can occur (often pleuritic) but is generally less immediately life-threatening than signs of inadequate oxygenation.

Question 9

The nurse is conducting a staff in-service on managing an acute burn. The nurse should reinforce the utilization of which formula to guide fluid resuscitation?

Accepted Answer

Answer reason: Major burns cause massive capillary leak and fluid shifts leading to hypovolemia, so early IV crystalloid needs are estimated using a validated resuscitation formula. The Parkland formula calculates 24-hour lactated Ringer’s volume as 4 mL per kg body weight per percent TBSA burned, then titrates to physiologic endpoints (especially urine output). The mL/kg/hr figures are urine output goals used to adjust fluids, not formulas to determine initial resuscitation volume. A fixed 30 mL/kg bolus is more consistent with sepsis/trauma initial bolus concepts and is not the standard burn resuscitation calculation.

Question 10

A nurse is teaching a group of clients with peripheral vascular disease about a smoking cessation program. Which physiologic effect of nicotine should the nurse explain to the group?

Accepted Answer

Answer reason: Nicotine stimulates the sympathetic nervous system, producing peripheral vasoconstriction and increased vascular resistance. In clients with peripheral vascular disease, this vasoconstriction reduces arterial lumen diameter, worsening tissue perfusion and contributing to ischemic pain and delayed wound healing. Increased resistance requires a higher pressure gradient to drive blood forward, which aligns with the concept of increased “force” needed for flow rather than improved circulation. The other options incorrectly describe nicotine as causing peripheral vasodilation or beneficial redistribution of blood flow, which is not the clinically relevant effect taught for smoking cessation in PVD.

Question 11

A nurse is caring for a client with ascites. What does the nurse consider to be the cause of the ascites?

Accepted Answer

Answer reason: Low plasma proteins, particularly albumin, reduce plasma oncotic pressure so the circulation cannot retain fluid, promoting third spacing and edema/ascites. This mechanism is common in liver disease where impaired protein synthesis contributes to fluid accumulation (often alongside portal hypertension). “Portal hypotension” is incorrect because portal hypertension (not low pressure) contributes to ascites, and potassium production is not a physiologic driver of peritoneal fluid formation.

Question 12

The nurse is observing a client with epilepsy have a sudden loss of muscle tone that lasts for a few seconds. The nurse is correct in identifying this as which of the following?

Accepted Answer

Answer reason: The key discriminator in the stem is the abrupt loss of tone lasting only seconds. Tonic-clonic seizures involve sustained stiffening followed by rhythmic jerking and typically longer duration with postictal confusion. Absence seizures cause brief staring spells with impaired awareness rather than loss of tone, and complex partial (focal impaired-awareness) seizures feature automatisms and altered consciousness.

Question 13

The nurse is caring for a client with suspected chronic venous insufficiency. Which of the following findings would support a diagnosis of chronic venous insufficiency?

Accepted Answer

Answer reason: This produces characteristic brown hyperpigmentation around the ankles/lower legs and is a classic supportive assessment finding. By contrast, absent pedal pulses and exertional calf cramping (claudication) point to arterial insufficiency. Arterial ulcers also tend to occur on toes with well-demarcated “punched-out” edges, making that option inconsistent with venous disease.

Question 14

The nurse is caring for a client with a pneumothorax. The nurse notes the client is experiencing dyspnea. Which of the following actions should the nurse take first?

Accepted Answer

Answer reason: Dyspnea in pneumothorax reflects impaired ventilation and reduced effective gas exchange, so the immediate priority is to optimize oxygenation per ABCs. Supplemental oxygen increases alveolar oxygen tension and can improve SpO2 while definitive treatment is arranged, reducing hypoxemia risk quickly and safely. High Fowler’s can help work of breathing, but it is less direct than increasing inspired oxygen concentration when the client is already symptomatic. Intubation and chest tube insertion may become necessary depending on severity (e.g., tension pneumothorax or worsening respiratory failure), but they are not the first nursing action when a rapid, noninvasive stabilizing intervention is available.

Question 15

The following are all nursing diagnoses appropriate for a gravida 1 para 0 in labor. Which one would be most appropriate for the primigravida as she completes the early phase of labor?

Accepted Answer

Answer reason: During early labor, especially for a primigravida, anxiety and pain commonly trigger hyperventilation, which can cause respiratory alkalosis, dizziness, and decreased oxygen release to tissues. This makes a respiratory-focused nursing diagnosis highly relevant as she transitions out of the early phase, when coping behaviors and breathing patterns are often most problematic. Addressing breathing control and reducing anxiety directly targets the physiologic consequence that can develop quickly during contractions. By comparison, uteroplacental perfusion problems are more specifically associated with supine positioning and later labor concerns, not the most typical primary issue at the end of early labor.

Question 16

Which assessment finding would strongly indicate the possibility of cirrhosis?

Accepted Answer

Answer reason: Peripheral edema is therefore a classic, strong clinical indicator of decompensated chronic liver disease. Hepatomegaly can occur in several liver conditions and may be absent in late cirrhosis when the liver becomes shrunken, making it less specific. Pruritus is more strongly associated with cholestasis and can be seen in other biliary disorders, so it is not as directly indicative of cirrhotic fluid/protein derangements.

Question 17

Which illness typically presents with headache, fever, and altered mental status?

Accepted Answer

Answer reason: Altered mental status in the setting of fever and headache points to inflammation/infection of brain parenchyma causing cerebral dysfunction. Encephalitis classically presents with fever, headache, and changes in cognition/behavior or level of consciousness, and may also include seizures or focal deficits. Meningitis more typically features meningeal irritation (nuchal rigidity, photophobia, Kernig/Brudzinski) and can have altered mentation, but it is less defining than in encephalitis. Pharyngitis and sinusitis commonly cause localized upper-respiratory symptoms and do not typically produce true altered mental status unless there are severe complications.

Question 18

A client experiences a nosebleed. The nurse documents this as?

Accepted Answer

Answer reason: Epistaxis is the medical term for bleeding from the nose, so it is the accurate documentation for a nosebleed. Precise terminology supports clear communication among the care team and guides appropriate follow-up (e.g., assessing for anticoagulant use or hypertension). Miosis refers to pupillary constriction, not a bleeding symptom. Hematoma is localized blood collection in tissue, and myalgia is muscle pain, making both incorrect for this finding.

Question 19

The nurse is assessing a client with cirrhosis. Which assessment finding would be most indicative of late-stage cirrhosis?

Accepted Answer

Answer reason: As liver failure and portal hypertension progress, intrapulmonary vascular dilation and ventilation-perfusion mismatch can produce dyspnea and measurable hypoxemia. Gastrointestinal symptoms like constipation, diarrhea, and vomiting are nonspecific and can occur at many stages or from diet/medications, so they are less indicative of advanced decompensation. Hypoxia reflects significant systemic physiologic derangement from end-stage liver disease and warrants urgent evaluation.

Question 20

Which condition is most closely associated with weight gain, nausea, and a decrease in urine output?

Accepted Answer

Answer reason: Reduced effective forward flow lowers renal perfusion and activates RAAS, promoting sodium/water retention and decreased urine output (oliguria). Hepatic and gastrointestinal venous congestion can produce abdominal fullness, anorexia, and nausea. By contrast, left-sided failure more classically presents with pulmonary congestion (dyspnea, crackles) rather than the predominant systemic fluid overload pattern described.

Question 21

A nurse is caring for a client with cardiomyopathy and is aware that the client is at high risk for developing?

Accepted Answer

Answer reason: Cardiomyopathy is a disease of the myocardium that commonly reduces ventricular contractility and/or impairs relaxation, lowering effective cardiac output. This makes progression to pump failure the most direct and expected complication, presenting with congestion, dyspnea, edema, and fatigue. Myocardial infarction is primarily due to acute coronary artery occlusion rather than myocardial muscle disease itself, so it is not the highest-risk “expected” development from cardiomyopathy alone. Diabetes mellitus and pericardial effusion are not typical direct sequelae of cardiomyopathy.

Question 22

The nurse would assess a client with varicose veins for which symptoms?

Accepted Answer

Answer reason: This typically produces a dull ache, heaviness, fatigue, and a sense of pressure or fullness that worsens with prolonged standing and improves with leg elevation. Cool feet is more consistent with impaired arterial perfusion rather than venous disease. Sharp, severe pain is less typical of uncomplicated varicosities and would raise concern for acute thrombosis or another pathology.

Question 23

A nurse determines that a client with varicose veins understands the cause of primary varicose veins when the client states which cause?

Accepted Answer

Answer reason: Pregnancy predisposes to this by increasing blood volume and causing hormonal smooth-muscle relaxation, while the gravid uterus increases venous pressure in the pelvis and lower extremities. These changes promote venous pooling and progressive valve failure, fitting the mechanism of primary varicosities. Thrombosis and trauma more often cause secondary varicose veins through obstruction or direct damage to venous valves. Systemic hypertension is not a primary driver of superficial venous valve failure in the legs.

Question 24

A client is admitted with a hiatal hernia. The nurse should assess the client for which symptom?

Accepted Answer

Answer reason: This most commonly presents as GERD-type symptoms such as heartburn and regurgitation, often worse after meals or when lying down. Referred pain to the left arm is more concerning for cardiac ischemia and is not a typical primary manifestation of hiatal hernia. Lower back pain and abdominal cramping are nonspecific and do not best match the expected symptom pattern for this condition.

Question 25

Documentation of an assessment by the nurse for a client diagnosed with a duodenal ulcer will most likely reveal which of the following findings?

Accepted Answer

Answer reason: A duodenal ulcer is a common cause of occult or overt upper GI bleeding, making this assessment finding likely. Vomiting of blood can occur but is more typical of brisk bleeding and is less common as the expected baseline finding. Pain patterns also differ: duodenal ulcer pain often improves with food rather than worsening during meals.

Question 26

A client is admitted with a C6 spinal injury. The nurse anticipates the client most likely has which condition?

Accepted Answer

Answer reason: A C6 injury interrupts motor and sensory pathways to the trunk and legs and significantly impairs upper-extremity function as well, producing tetraplegia. Paraplegia is more typical of thoracic or lumbar cord injury where arm function is spared. Aphasia and hemiparesis are cortical (brain) findings rather than spinal cord level syndromes.

Question 27

Which finding is expected by the nurse when assessing a child with an acyanotic heart defect?

Accepted Answer

Answer reason: Right-sided heart strain and systemic venous congestion from heart failure commonly cause liver enlargement in infants and children. Expected assessment findings therefore include hepatomegaly along with tachypnea, feeding difficulty, and poor weight gain. By contrast, bradycardia and decreased respiratory rate are not typical; respiratory rate more often increases as pulmonary congestion worsens.

Question 28

What is the best way for a nurse to position an infant with a diaphragmatic hernia before surgery?

Accepted Answer

Answer reason: Positioning the infant with the affected side down uses gravity to keep herniated abdominal contents lower and helps the unaffected lung expand more effectively. This also supports oxygenation while awaiting surgical repair, when definitive correction is not yet possible. Supine positioning can worsen lung compression, and Trendelenburg can increase pressure on the diaphragm and compromise respiratory mechanics.

Question 29

A mother reports that her teenager is losing hair in small round areas on the scalp. The nurse interprets this as suggesting which condition?

Accepted Answer

Answer reason: This presentation differs from dandruff-related conditions, which typically cause scaling and diffuse shedding rather than discrete bald patches. The other options are eye disorders and do not explain scalp hair loss. Therefore the described finding most strongly indicates alopecia.

Question 30

Which nursing diagnosis is appropriate for a client with acute asthma?

Accepted Answer

Answer reason: A nursing diagnosis centered on limited ability to tolerate activity best matches this pathophysiology because even minor exertion can worsen dyspnea and trigger increased respiratory distress. The other choices do not address the primary acute problem of impaired ventilation and oxygenation; fluid overload and constipation are not expected defining features of an acute asthma attack. The priority is recognizing reduced functional capacity related to respiratory compromise and planning interventions that minimize oxygen demand and support breathing.

Question 31

Which nursing diagnosis is the priority for an infant with bronchiolitis?

Accepted Answer

Answer reason: Using ABC priorities, problems affecting oxygenation take precedence over psychosocial or activity needs. This diagnosis directly targets the most immediate risk: inadequate oxygen transfer at the alveolar-capillary level. Nutrition concerns are common due to tachypnea and poor feeding, but they are secondary unless airway and oxygenation are stabilized first.

Question 32

A client is diagnosed with pneumonia. Which nursing diagnosis would take priority for this client?

Accepted Answer

Answer reason: Pneumonia commonly causes increased secretions and inflammation that obstruct airflow and reduce gas exchange, making maintaining a patent airway the most urgent nursing problem. Interventions targeting clearance (positioning, coughing/deep breathing, suctioning as needed) directly reduce hypoxemia risk and respiratory deterioration. Fluid volume issues, activity limits, and education are important but are secondary once airway patency and adequate oxygenation are stabilized.

Question 33

Which factor should be the initial focus of nursing management in a client with acute pancreatitis?

Accepted Answer

Answer reason: Immediate nursing priorities center on stabilizing physiologic status and relieving severe symptoms; analgesia and comfort measures support effective breathing, participation in care, and overall hemodynamic stability. Nutritional measures are important but are not the first focus because patients are commonly kept NPO initially to reduce pancreatic stimulation and are managed with IV fluids and symptom control. Hypoglycemia is not the most typical immediate problem (hyperglycemia is more common from impaired insulin secretion), and skin breakdown prevention is supportive but not an initial priority over severe acute pain.

Question 34

Which procedure is most likely necessary for a client with a small tumor confined to one liver segment or lobe?

Accepted Answer

Answer reason: Surgical resection is preferred when the tumor is resectable and hepatic reserve is adequate, and local ablative techniques such as cryoablation are appropriate alternatives for small, confined lesions or when resection is less feasible. Transplant is generally reserved for unresectable disease within strict criteria or when underlying liver failure/cirrhosis limits safe resection. Chemotherapy-only or radiation-only approaches are typically not definitive for a small, localized lesion when curative local therapy is possible.

Question 35

A nurse is documenting care for a client with iron deficiency anemia. What is the most appropriate nursing diagnosis?

Accepted Answer

Answer reason: This problem is best captured by a diagnosis addressing inadequate oxygenation at the blood level rather than ventilation mechanics or airway patency. Airway clearance and breathing pattern diagnoses focus on obstructed airways or abnormal respiratory mechanics, which are not primary issues in uncomplicated iron deficiency anemia. Deficient fluid volume is only appropriate if there is evidence of dehydration or acute blood loss contributing to hypovolemia, which is not inherent to iron deficiency anemia.

Question 36

A client has just begun exhibiting signs of myasthenia gravis. The nurse anticipates assessment of the client to include?

Accepted Answer

Answer reason: Myasthenia gravis is an autoimmune disorder that impairs neuromuscular transmission, producing fluctuating, fatigable weakness that often starts in ocular muscles. Early manifestations commonly include eyelid droop and diplopia that worsen with activity. This fits best with an assessment finding of ocular weakness rather than systemic features. A common distractor is fatigue improving at the end of the day, which is opposite of the typical pattern (symptoms worsen as the day progresses). Dysphagia and respiratory distress can occur later or in exacerbations, but are less characteristic as the initial, most expected early sign.

Question 37

A nurse is evaluating a client to determine the extent of Parkinson’s disease. The nurse would observe for which symptom?

Accepted Answer

Answer reason: This produces classic motor findings such as bradykinesia, resting tremor, postural instability, and rigidity that can be assessed on physical exam to gauge disease severity. Rigidity (e.g., cogwheel or lead-pipe) is therefore an expected observation when evaluating extent of disease. Bulging eyeballs suggests thyroid eye disease, and diminished distal sensation is more consistent with peripheral neuropathy rather than a primary parkinsonian motor disorder. Increased dopamine levels contradict the core pathophysiology of Parkinson’s disease.

Question 38

An elderly client developed pneumonia. The nurse is aware that the initial symptom the client may manifest is?

Accepted Answer

Answer reason: Older adults often present with atypical infection signs because of decreased immune response and blunted febrile reaction. Early pneumonia in this population may manifest as acute confusion/delirium, lethargy, poor intake, and signs of dehydration rather than prominent respiratory complaints. These changes reflect systemic effects of infection and hypoxemia, plus reduced physiologic reserve. Fever/chills and pleuritic pain/cough can occur, but they are less reliable as initial findings in the elderly and may appear later or be minimal.

Question 39

An emergency room nurse is assessing a pediatric client in heart failure. Which symptom is consistent with a diagnosis of left-sided heart failure?

Accepted Answer

Answer reason: This leads to fluid shifting into the lung interstitium/alveoli, producing respiratory findings such as increased work of breathing, tachypnea, and dyspnea. In contrast, peripheral edema and neck vein distention are more characteristic of right-sided heart failure due to systemic venous congestion. Although weight gain can occur from fluid retention in heart failure, it is less specific than the hallmark pulmonary symptoms seen with left-sided failure.

Question 40

The nurse is assessing the stool of a child with celiac disease. How would the nurse expect the stool to appear?

Accepted Answer

Answer reason: Fat malabsorption produces steatorrhea, which is bulky, pale, foul-smelling, and may appear greasy or frothy due to increased fat content and gas. This expected finding fits the child’s underlying pathophysiology rather than a colonic motility problem. A classic contrasting distractor is red currant jelly stool, which points to intussusception rather than chronic malabsorption.

Question 41

When assessing a neonate, the nurse notes visible peristaltic waves across the epigastrium. This characteristic is indicative of which disorder?

Accepted Answer

Answer reason: In hypertrophic pyloric stenosis, pyloric muscle thickening creates a gastric outlet obstruction that produces prominent peristalsis and classically progresses to nonbilious projectile vomiting in early infancy. This finding is not typical of imperforate anus, which presents with failure to pass meconium and abdominal distention rather than gastric peristaltic waves. Intussusception more often presents later with intermittent severe abdominal pain and “currant jelly” stools, not a neonatal epigastric peristaltic pattern.

Question 42

When assessing an infant diagnosed with a diaphragmatic hernia, the nurse would expect the mediastinum to?

Accepted Answer

Answer reason: A congenital diaphragmatic hernia allows abdominal organs to herniate into the thoracic cavity, increasing intrathoracic pressure on the involved side. This mass effect compresses the ipsilateral lung and displaces the mediastinum away from the herniated contents. Mediastinal shift contributes to respiratory distress by further compromising lung expansion and can impair venous return depending on severity. A common confusion is thinking the shift occurs toward the affected side; that would imply volume loss (e.g., atelectasis), whereas this condition creates space-occupying pressure.

Question 43

Before surgery, which nursing intervention should be used for an infant with a diaphragmatic hernia?

Accepted Answer

Answer reason: In congenital diaphragmatic hernia, bowel in the thorax compresses the lungs, so any increase in intrathoracic pressure worsens ventilation and oxygenation. Crying increases swallowed air and gastric distention, which can further elevate the diaphragm and reduce lung expansion, worsening respiratory compromise. Preoperative care focuses on minimizing stress and maintaining effective respiration while awaiting definitive surgical repair. Feeding is avoided due to aspiration risk and worsening distention, and positioning alone is less critical than preventing exacerbations of respiratory distress.

Question 44

Infants with neonatal chronic lung disease (bronchopulmonary dysplasia) require frequent, prolonged rest periods. Which sign indicates overstimulation?

Accepted Answer

Answer reason: A classic stress/overstimulation cue in fragile neonates is a color change due to desaturation, which presents as cyanosis and signals the need to stop stimulation and allow recovery. This finding is clinically urgent because it reflects impaired gas exchange rather than a behavioral state. In contrast, increased alertness and good eye contact are generally signs of engagement/organization rather than physiologic decompensation. Lethargy may indicate fatigue or illness, but it is less specific than an acute oxygenation-related sign during stimulation.

Question 45

A 2-year-old child has been diagnosed with asthma. The parents ask about the most common asthma triggers. What is the best response by the nurse?

Accepted Answer

Answer reason: Temperature and humidity shifts, cold air, and seasonal changes can precipitate bronchospasm in many children, making this a broadly applicable and common trigger to teach families. Animal dander can be a trigger for sensitized children, but it is not universally the most common across patients and depends on specific allergen exposure. Family history increases risk for developing asthma but is not an acute trigger for symptoms.

Question 46

The nurse is caring for a client showing symptoms of bronchial obstruction. Which assessment finding would the nurse expect to find?

Accepted Answer

Answer reason: This finding is a common bedside clue of reduced ventilation from mucus plugging, bronchospasm, or airway narrowing, and may be accompanied by wheezing or prolonged expiration. A hacking cough can occur with many respiratory conditions and is not specific for obstruction severity. Rust-colored sputum is more suggestive of pneumococcal pneumonia, and accessory muscle use typically increases (not decreases) when work of breathing rises from obstruction.

Question 47

Which goal will the nurse make the highest priority in a client with a new tracheostomy?

Accepted Answer

Answer reason: Early postoperative care focuses on assessing breath sounds, work of breathing, oxygenation, and ensuring the tracheostomy remains unobstructed with appropriate suctioning and humidification. Infection prevention is important but is a longer-term risk compared with acute airway compromise. Communication and self-care goals are appropriate once ventilation/oxygenation is stabilized and the airway is reliably secure.

Question 48

The nurse is caring for the child who has liver enlargement secondary to infective endocarditis. The nurse should assess the child for which associated complication?

Accepted Answer

Answer reason: Right-sided failure leads to backup of blood in the venous system, causing liver enlargement and often peripheral edema, jugular venous distention, and weight gain from fluid retention. Infective endocarditis can damage valves (especially tricuspid in some cases) or worsen cardiac function, precipitating this hemodynamic complication. Pulmonary hypertension can contribute to right heart strain but hepatomegaly as the noted finding most specifically cues assessment for right-sided failure rather than primary pulmonary vascular disease. Myocardial infarction and tetralogy of Fallot do not best explain liver congestion as the key associated complication in this scenario.

Question 49

The child is hospitalized with acute LTB. In developing a plan of care, which nursing problem should the nurse consider the priority?

Accepted Answer

Answer reason: Acute LTB (laryngotracheobronchitis/croup) causes upper-airway inflammation and edema, leading to stridor, increased work of breathing, and potential airway obstruction, making breathing effectiveness the most immediate threat. Addressing ventilation supports oxygenation while other concerns are managed concurrently. Anxiety and knowledge deficits are important but are secondary to stabilizing respiratory status. Dehydration risk can occur from poor intake/tachypnea but is addressed after ensuring adequate airway and breathing.

Question 50

The nurse is planning care for the infant newly diagnosed with tracheoesophageal fistula. Which potential problem should be the nurse’s priority?

Accepted Answer

Answer reason: Using airway-breathing circulation priorities, preventing aspiration and respiratory compromise is the most immediate life-threatening concern. Aspiration can rapidly lead to choking, hypoxemia, and chemical pneumonitis, requiring urgent nursing actions such as NPO status and suctioning. Infection and nutrition problems are important but are typically downstream consequences of repeated aspiration. Attachment concerns are not urgent compared with maintaining a patent, protected airway.

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