Question 1

Which nursing intervention is appropriate for care of the child with cystic fibrosis?

Accepted Answer

Answer reason: Cystic fibrosis causes thick, tenacious airway secretions that require routine airway-clearance measures to prevent obstruction, atelectasis, and infection. Scheduled chest physiotherapy multiple times daily helps mobilize secretions and improves ventilation and gas exchange as part of standard CF care. Exercise is generally encouraged (with adequate hydration and rest) because it can aid airway clearance rather than being restricted. Bronchodilators are typically given before airway clearance to open airways and enhance mucus mobilization, making the “after” timing less appropriate.

Question 2

The client diagnosed with a brain tumor was admitted to the ICU with decorticate posturing. Which indicates that the client’s condition is improving?

Accepted Answer

Answer reason: Purposeful movement to pain reflects a higher, more organized neurologic response and is a better motor outcome on neurologic assessment than abnormal posturing. Decorticate posturing indicates severe cortical/subcortical injury, but the ability to localize or respond purposefully suggests improved cortical function and less brainstem involvement. Progression from decorticate to decerebrate posturing would indicate worsening with more caudal brainstem dysfunction. Flaccidity with no response represents an even poorer neurologic status, suggesting profound dysfunction or impending herniation.

Question 3

A client with a history of myasthenia gravis is admitted to the emergency department with complaints of respiratory distress. The client's condition worsens, and arterial blood gases are drawn. The nurse anticipates that the client will develop which condition?

Accepted Answer

Answer reason: Hypoventilation causes CO2 retention, which increases PaCO2 and lowers blood pH, producing an acid-base disturbance of primary respiratory origin. This is the expected ABG pattern when respiratory failure is due to neuromuscular weakness rather than a metabolic process. A common distractor is respiratory alkalosis, which would be more consistent with early hyperventilation from anxiety or pain, not progressive ventilatory muscle fatigue and CO2 retention.

Question 4

The nurse is teaching a student nurse about the purpose of diaphragmatic breathing exercises for a client with chronic obstructive pulmonary disease (COPD). Which statement by the nurse is correct?

Accepted Answer

Answer reason: Diaphragmatic breathing in COPD is used to improve the efficiency of ventilation by promoting better diaphragmatic excursion, reducing accessory muscle use, and helping move air in and out of the lungs more effectively. This technique can help lessen air trapping and improve distribution of ventilation, which supports better gas exchange. The other options describe physiologic changes that would worsen COPD mechanics (reduced vital capacity, increased residual volume, or decreased alveolar ventilation) rather than being therapeutic goals. While breathing exercises do not directly act as a bronchodilator medication, among the given choices this is the only statement aligned with improving airflow rather than impairing it.

Question 5

A child with cystic fibrosis has a bronchodilator, steroids ordered by metered-dose inhaler, and chest physiotherapy. In which order should these medications and treatments be administered?

Accepted Answer

Answer reason: Airway-opening therapies should be given before treatments that mobilize secretions so mucus can be moved and cleared more effectively. A bronchodilator decreases bronchospasm and improves airflow, which enhances the effectiveness and tolerance of subsequent chest physiotherapy. Inhaled corticosteroids are used to reduce airway inflammation but do not provide the immediate airway opening needed to optimize secretion clearance. Eating immediately before chest physiotherapy increases the risk of nausea/vomiting and aspiration and can reduce the child’s ability to participate in the treatment.

Question 6

The nurse is admitting a client with hypothyroidism. During the initial assessment, which of the following symptoms should the nurse be alert for?

Accepted Answer

Answer reason: This leads to fatigue from reduced energy production, cold intolerance from decreased thermogenesis, and weight gain from lower basal metabolic rate and fluid accumulation. Gastrointestinal motility slows, making constipation a classic presenting symptom. In contrast, heat intolerance, nervousness, and weight loss are more consistent with hyperthyroidism, while polyuria/polydipsia suggests diabetes mellitus and coarsened features with extremity enlargement suggests acromegaly.

Question 7

A nurse is caring for clients who have a history of genital herpes infection. Which client is most at risk for an outbreak of genital herpes?

Accepted Answer

Answer reason: Tingling, burning, itching, or paresthesias in the genital area commonly occur hours to days before vesicular lesions erupt, making this presentation the strongest predictor of an impending outbreak. Systemic symptoms like headache and fever are nonspecific and may occur with many infections and do not reliably indicate HSV recurrence. Vaginal/urethral discharge is more typical of cervicitis or urethritis (e.g., chlamydia/gonorrhea) rather than an HSV prodrome.

Question 8

The nurse is caring for the client newly diagnosed with hypothyroidism. Which problem should the nurse include in the plan of care?

Accepted Answer

Answer reason: This commonly leads to weight gain and constipation rather than hypermotility with diarrhea, making that distractor inconsistent with the condition. Fatigue and lethargy can also reduce appetite and the ability to prepare/consume meals, so identifying a nutrition-related problem is appropriate for a care plan. The activity intolerance in hypothyroidism is related to decreased, not increased, metabolic rate, and cognitive slowing is more likely to manifest as slowed thinking/speech rather than primarily producing anxiety as the key nursing problem.

Question 9

The client with a history of a duodenal ulcer is hospitalized with upper abdominal discomfort and projectile vomiting that has a foul odor. The nurse immediately notifies the HCP, concluding that the client may have developed which complication?

Accepted Answer

Answer reason: Chronic duodenal ulcer inflammation and scarring can narrow the pylorus/duodenal outlet, creating a mechanical obstruction and leading to large-volume emesis. This presentation is more consistent with obstruction than hemorrhage, which would typically produce hematemesis or melena with signs of hypovolemia. Perforation would more often present with sudden severe pain, rigid abdomen, and peritoneal signs rather than recurrent foul-smelling vomiting.

Question 10

After Billroth ii surgery (gastrojejunostomy), the client experiences weakness, diaphoresis, anxiety, and palpitations 2 hours after a high-carbohydrate meal. The nurse should interpret that these symptoms indicate the development of which problem?

Accepted Answer

Answer reason: The resulting hypoglycemia produces adrenergic symptoms such as diaphoresis, palpitations, anxiety, and weakness, matching the timing and presentation described. This pattern is classically associated with gastric surgeries like Billroth II that bypass normal pyloric regulation and speed gastric emptying. Early dumping would present sooner (within 30–60 minutes) with more prominent GI symptoms and vasomotor flushing rather than hypoglycemic symptoms.

Question 11

The client receives treatment for uncomplicated lower-extremity cellulitis. The nurse notes improvement in the client’s condition when which observation is noted on assessment?

Accepted Answer

Answer reason: Reduced edema indicates less capillary leak and tissue inflammation and is a direct bedside sign the infection and inflammatory response are resolving. Increased erythema suggests progression rather than improvement, and an elevated WBC of 14,000/mm3 is consistent with ongoing infection/inflammation. Palpable strong pedal pulses may be normal at baseline and are not a primary indicator of cellulitis resolution.

Question 12

A 17-year-old female receives treatment for primary amenorrhea caused by hyperthyroidism. Which finding during a clinic visit should indicate to the nurse that treatment for amenorrhea was effective?

Accepted Answer

Answer reason: Resumption of menstrual periods is the most direct and specific evidence that the amenorrhea has resolved. Findings like weight gain or reduced tremor suggest improvement of hyperthyroid symptoms but do not confirm return of menses. Absence of menstrual cramps is nonspecific and can occur even with normal cycles.

Question 13

The ED nurse is assessing the adolescent who has burns over 25% of the body. Which assessment finding should be most concerning to the nurse?

Accepted Answer

Answer reason: Waxy white, non-blanching burn appearance is most consistent with a deep full-thickness injury, reflecting destruction of dermis, blood vessels, and nerve endings. With >25% TBSA, full-thickness areas significantly increase risk for major fluid shifts, burn shock, and require urgent burn-center level management including aggressive resuscitation and potential excision/grafting. In contrast, moist/red and red blistering findings are more typical of superficial partial-thickness burns, which generally have better perfusion and healing potential. Mottling can indicate perfusion issues, but a clearly full-thickness descriptor signals the most severe tissue damage and highest complication burden in this context.

Question 14

The nurse assesses that the immunocompromised 5-month-old infant is diaphoretic and has thick, tenacious secretions, poor cough effort, diarrhea, and anorexia. Which nursing problem should the nurse establish as priority?

Accepted Answer

Answer reason: Thick, tenacious secretions combined with poor cough effort indicate the infant cannot mobilize mucus effectively, raising the risk of obstruction and impaired gas exchange. Diaphoresis in an infant can be an early sign of increased work of breathing and physiologic stress, further supporting an urgent respiratory priority. Although diarrhea and anorexia increase concern for dehydration and inadequate intake, these are typically secondary once airway patency and ventilation are addressed. Risk for infection is important in an immunocompromised infant, but the stem describes an active airway clearance problem needing immediate intervention.

Question 15

A neonate returns from the operating room after surgical repair of a tracheoesophageal fistula and esophageal atresia. Which nursing intervention should be performed immediately?

Accepted Answer

Answer reason: Airway and breathing are the immediate postoperative priorities for a neonate, especially after repair involving the trachea and esophagus where edema, secretions, or compromised ventilation can rapidly cause hypoxia. Ensuring a patent airway supports adequate oxygenation and early recognition of respiratory distress, which is the most time-sensitive threat. Initiating feeds is contraindicated immediately because the anastomosis must be protected and oral/NG feeding is typically delayed until ordered and confirmed safe. Allowing holding may be appropriate later, but only after physiologic stability and airway/respiratory status are secured.

Question 16

An infant is being treated with antibiotic therapy for otitis media and develops an erythematous, fine, raised rash in the groin and suprapubic area. Which instruction or explanation will most likely be given to the mother?

Accepted Answer

Answer reason: Antibiotic therapy disrupts normal bacterial flora, allowing yeast overgrowth, which commonly presents as a bright erythematous diaper-area rash involving the groin folds. The suprapubic/groin distribution with a fine raised appearance is more consistent with Candida dermatitis than simple irritant diaper rash. Changing diaper brands or using non-specific OTC barrier products does not address the underlying fungal cause and may delay effective treatment. Abruptly stopping antibiotics is not indicated for this localized yeast overgrowth and risks undertreating otitis media unless a true drug allergy is suspected by other systemic findings.

Question 17

The parents of a child ask the nurse what the best intervention is if their child is experiencing an episode of “midnight croup,” or acute spasmodic laryngitis. What is the best response by the nurse?

Accepted Answer

Answer reason: Acute spasmodic laryngitis (croup) causes upper-airway edema and laryngeal spasm, so the immediate goal is to reduce airway swelling and ease inspiratory stridor. Cool, humidified air helps soothe inflamed mucosa and can decrease airway edema, often improving symptoms quickly at home while the child is kept calm. Warm liquids do not address the laryngeal narrowing and may be difficult to swallow during respiratory distress. Raising room heat and using a warm shower can increase ambient warmth and may not reduce edema as effectively as cool mist for classic “midnight croup.”.

Question 18

The nurse is assessing the client experiencing a left-sided cerebrovascular accident (CVA). Which clinical manifestations would the nurse expect the client to exhibit?

Accepted Answer

Answer reason: A left-hemispheric stroke typically produces contralateral motor deficits because corticospinal tracts decussate, so weakness or paralysis is expected on the right side. The left hemisphere is dominant for language in most individuals, so injury commonly causes aphasia (expressive, receptive, or mixed). Option A is inconsistent because a left-sided lesion would not primarily cause left-arm hemiparesis. The combination of right-sided paralysis with a language deficit is the classic presentation pattern for a left CVA.

Question 19

A 62-year-old client is admitted to the hospital with pneumonia. He has a history of Parkinson’s disease, which his family says is progressively worsening. Which symptom will the nurse most likely observe when assessing the client?

Accepted Answer

Answer reason: As the disease advances, hypophonia and dysarthria occur from reduced motor control of speech muscles, making altered speech a frequent observable finding. Muscle flaccidity is more consistent with lower motor neuron or acute neuromuscular disorders rather than parkinsonian rigidity. Tremor in Parkinson’s is classically a resting tremor that lessens with intentional movement, so worsening tremor with purposeful movement suggests a different process (e.g., intention tremor).

Question 20

The client with class II HF according to the New York Heart Association Functional Classification has been taught about the initial treatment plan for this disease. The nurse determines that the client needs additional teaching if the client states that the treatment plan includes which component?

Accepted Answer

Answer reason: Diuretics are used to control volume overload and relieve congestion, and ACE inhibitors are foundational therapy to reduce remodeling and improve outcomes. Sodium restriction is a standard nonpharmacologic intervention to help prevent fluid retention and exacerbations. Home oxygen is not a routine component of initial HF management unless there is concurrent hypoxemia or a separate pulmonary indication, so including it suggests misunderstanding.

Question 21

The nurse is taking the history from the parent of the infant with Hirschsprung’s disease. Which statement is the parent most likely to make?

Accepted Answer

Answer reason:  Hirschsprung’s disease is due to absent enteric ganglion cells in the distal bowel, causing functional obstruction and severe constipation. Stool may be thin/ribbonlike from passage through a narrowed aganglionic segment and can be foul-smelling from prolonged stasis and bacterial overgrowth. Projectile vomiting with peripheral edema suggests other GI or systemic disorders rather than distal colonic aganglionosis. Evening crying with leg/fist clenching is more consistent with infantile colic than an obstructive motility disorder.

Question 22

The nurse is developing the plan of care for the 5-year-old about to have a tonsillectomy and adenoidectomy (T&A). Which problem should the nurse establish as priority?

Accepted Answer

Answer reason: After T&A, the child is at risk for retained secretions and aspiration of blood/secretions; reluctance to cough because of throat pain can rapidly compromise ventilation. Identifying airway clearance as the priority directs nursing care toward maintaining patency, positioning, and monitoring for obstruction/bleeding. Pain and anxiety are important but are addressed after ensuring an adequate airway, and nutrition is a longer-term concern rather than an immediate safety threat.

Question 23

A client in a long-term care facility has been receiving continuous tube feedings. The nurse notes the client has a cough producing tan sputum and is now febrile to 102.7°F (38.9° C). The nurse auscultates the client’s lung fields and hears bronchial breath sounds in the right middle lobe. The nurse suspects the client may have developed?

Accepted Answer

Answer reason: Continuous tube feedings increase aspiration risk, especially in long-term care, and aspiration commonly leads to an acute infectious process with fever and productive sputum. Localized bronchial breath sounds over a specific lobe suggest alveolar consolidation, which is characteristic of pneumonia rather than a diffuse bronchial inflammation. Atelectasis more often causes low-grade fever early post-op with diminished breath sounds/crackles rather than purulent sputum and focal bronchial sounds. Pulmonary embolism typically presents with sudden dyspnea/pleuritic pain and may have a normal lung exam without purulent sputum or lobar bronchial breath sounds.

Question 24

The nurse is assessing a 69-year-old client who appears thin and cachectic. The client is short of breath at rest, dyspneic with the slightest exertion, and has diminished breath sounds with deep inspiration. The nurse interprets these assessment findings as indicative of?

Accepted Answer

Answer reason: The core principle is that emphysema causes alveolar destruction and hyperinflation, reducing effective gas exchange and making breathing effortful even at rest. The classic clinical phenotype includes thin/cachectic body habitus (“pink puffer”), marked dyspnea with minimal exertion, and decreased breath sounds due to overdistended, poorly ventilated lung units. Diminished breath sounds with deep inspiration aligns with air trapping and reduced airflow movement typical of emphysema. In contrast, chronic obstructive bronchitis more often presents with productive cough and a stockier, cyanotic appearance, while asthma is episodic with wheezing rather than persistent cachexia and chronically diminished breath sounds.

Question 25

The nursing care plan for an infant with neonatal chronic lung disease (bronchopulmonary dysplasia) includes the nursing diagnosis of impaired gas exchange. Which nursing action would be most appropriate for a nurse to include?

Accepted Answer

Answer reason: Impaired gas exchange in bronchopulmonary dysplasia is driven by compromised alveolar ventilation and ventilation–perfusion mismatch, often worsened by retained secretions and atelectasis. Airway clearance measures improve ventilation by mobilizing secretions and helping open previously under-ventilated lung regions, which supports more effective oxygen and carbon dioxide exchange. Nutritional support, developmental stimulation, and bonding are important supportive interventions but do not directly correct the physiologic problem of impaired gas exchange. A common distractor is enteral feedings, which addresses growth and energy demands but is secondary when the care plan focus is improving oxygenation/ventilation.

Question 26

The client being admitted for same-day surgery has inspiratory crackles and bilateral wheezes, and reports shortness of breath for several days. Which intervention should the nurse implement first?

Accepted Answer

Answer reason: The priority is immediate support of oxygenation and ventilation using ABCs because the client has active respiratory compromise (crackles, wheezes, and several days of dyspnea). Supplemental oxygen is a rapid, nurse-initiated intervention that can improve hypoxemia while further evaluation and provider notification occur. Notifying the surgeon is important because surgery may need to be delayed, but it does not address the client’s current physiologic instability as quickly. Incentive spirometry is mainly preventive/adjunct for atelectasis and is not the first action for acute shortness of breath, and documentation follows urgent stabilization.

Question 27

Which prevention measures should the nurse include when instructing a client on how to avoid otitis externa?

Accepted Answer

Answer reason: Otitis externa (“swimmer’s ear”) is commonly triggered by retained moisture in the external ear canal, which promotes maceration of the skin and bacterial overgrowth. Drying the ear canal after water exposure reduces this moisture and helps preserve the protective barrier of the canal. Astringent or acidifying drops can help restore an unfavorable environment for pathogen growth after swimming/bathing. Other options address unrelated infection-prevention or condition-specific prophylaxis (e.g., endocarditis prophylaxis) and do not target the key modifiable risk factor for otitis externa.

Question 28

A client complains of acute onset of periumbilical pain that is well localized over McBurney’s point. This pain is accompanied by a low-grade fever. As the client is triaged, the nurse palpates the left lower quadrant, causing the client to complain of right lower quadrant pain. Which sign does this best describe?

Accepted Answer

Answer reason: Referred pain to the right lower quadrant when the left lower quadrant is palpated indicates peritoneal irritation consistent with acute appendicitis. This maneuver increases pressure and stretches the inflamed peritoneum, provoking pain at the site of inflammation near McBurney’s point. The presentation of periumbilical pain migrating/localizing to the RLQ with low-grade fever further supports appendiceal inflammation. In contrast, Homans’ sign relates to suspected DVT, and Kernig’s sign is associated with meningeal irritation in meningitis.

Question 29

Which nursing diagnosis is appropriate for a client with chronic obstructive pulmonary disease who is anxious, dyspneic, and hypoxic?

Accepted Answer

Answer reason: This diagnosis targets the primary, modifiable physiologic problem nurses assess and manage with interventions like positioning, coughing techniques, hydration, bronchodilators as ordered, and suctioning if needed. Anxiety can worsen respiratory effort, but it is usually secondary to impaired ventilation/oxygenation rather than the main underlying issue to diagnose first. The impaired gas exchange option is less fitting because it attributes hypoxia to reduced oxygen-carrying capacity (e.g., anemia/CO exposure) rather than ventilation-perfusion mismatch and airflow limitation seen in COPD.

Question 30

The nurse is preparing to care for the client diagnosed with hepatitis A. Which interventions should the nurse plan to include?

Accepted Answer

Answer reason: With acute viral hepatitis, the priority is preventing additional hepatocellular injury while the liver is inflamed and metabolically stressed. Alcohol and acetaminophen are both hepatotoxic and can worsen liver inflammation or precipitate acute liver injury, so patient teaching to avoid these is a key nursing intervention. A common dietary teaching is small, frequent meals that are easier to tolerate with anorexia/nausea, making three large meals less appropriate. Hepatitis A is primarily fecal–oral, so routine care focuses on hand hygiene/standard precautions rather than universal mask-and-gown use.

Question 31

The nurse is caring for the client in an ED who has five fractured ribs from blunt chest trauma. The client is rating pain at 9 out of 10 on a 0 to 10 scale. When contacting the HCP, the nurse should advocate for which pain management option?

Accepted Answer

Answer reason: Regional techniques provide strong pain control at the chest wall while minimizing systemic sedation and respiratory depression compared with escalating systemic opioids. This improves the ability to cough, deep-breathe, and participate in pulmonary hygiene, which is critical with multiple rib fractures. Oral agents are typically inadequate for 9/10 acute traumatic pain, and meperidine is a poor opioid choice due to neurotoxic metabolites and safety concerns, especially with frequent dosing.

Question 32

The teenage client has been given education regarding goals of GH for treatment of hypopituitarism. The nurse determines that the client has adequate understanding of the treatment goals when making which statement?

Accepted Answer

Answer reason:  The core goal of growth hormone therapy in pediatric/teen hypopituitarism is to restore linear growth velocity to a normal range and optimize final adult height when epiphyseal plates are still open. This statement reflects the expected therapeutic outcome of treatment rather than a monitoring task. Tracking growth on a chart is important but describes evaluation/monitoring, not the treatment goal itself. Claims about preventing dental problems or building significant muscle mass misrepresent typical primary outcomes of GH replacement in this context.

Question 33

The nurse is caring for the child diagnosed with celiac disease. The parent is describing the number, consistency, appearance, and size of the child’s stools- Which changes in the child’s stools should prompt the nurse to conclude that the child’s ability to absorb nutrients is improving?

Accepted Answer

Answer reason: When absorption improves (typically after effective gluten restriction), stool volume decreases and stools become less bulky, greasy, and foul-smelling. The disappearance of this classic malabsorption pattern is the best indicator that nutrient absorption is improving. Other stool descriptions listed are more consistent with different pathologies (e.g., intussusception or obstructive/diarrheal processes) and do not specifically track recovery of intestinal absorptive function in celiac disease.

Question 34

The nurse performs a follow-up assessment of a client who was involved in a motor vehicle accident and sustained massive head injuries. The client is weaned off the ventilator and is breathing independently. The nurse notices the client’s respirations have a rhythmic crescendo and decrescendo of rate and depth of respiration and include brief periods of apnea. This type of respiratory pattern is?

Accepted Answer

Answer reason: A waxing-and-waning (crescendo–decrescendo) pattern of respirations with intermittent periods of apnea is characteristic of Cheyne–Stokes breathing. This reflects instability of the respiratory control centers, which can occur with severe neurologic injury. Ataxic breathing is irregular in rate and depth without a predictable crescendo–decrescendo rhythm, and apneustic respirations are prolonged inspiratory “holds.” Cluster breathing features groups of breaths with irregular pauses but lacks the classic gradual increase and decrease in depth seen here.

Question 35

In the unconscious client, noxious stimuli may elicit an abnormal motor response. When assessing a client, the nurse finds that in response to painful stimuli, the upper extremities exhibit flexion of the arm, wrist, and fingers with adduction of the limb. The lower extremity exhibits extension, internal rotation, and plantar flexion. This is known as?

Accepted Answer

Answer reason: Decorticate posturing reflects severe central nervous system injury above the brainstem, producing abnormal flexion in the upper extremities with adduction while the lower extremities extend, internally rotate, and plantar-flex. The described pattern of arm, wrist, and finger flexion with leg extension matches this classic response to painful stimuli. In contrast, decerebrate posturing is characterized by extension (not flexion) of the arms with pronation and indicates more caudal brainstem involvement, which does not fit the stem. Recognizing the posture pattern helps the nurse rapidly identify neurologic deterioration and need for urgent evaluation.

Question 36

A client who has been drinking alcohol for 30 years asks a nurse if permanent damage has occurred to his immune system. What is the best response by the nurse?

Accepted Answer

Answer reason: " Chronic alcohol use can cause clinically significant immune dysfunction, including impaired barrier defenses and reduced effectiveness of innate and adaptive immune responses, which increases susceptibility to infections. This directly addresses the client’s question about immune system damage with a clear, accurate physiologic effect that is observable in health outcomes. The metabolism statement is nonspecific and does not answer the immune-focused concern. The other responses are either dismissive or overly vague and do not provide the best therapeutic, factual teaching about immune consequences.

Question 37

The ED nurse completes an initial assessment of the 12-year-old child and thinks the child may be experiencing acute appendicitis. Which statement by the child would support the nurse’s conclusion?

Accepted Answer

Answer reason:  Acute appendicitis classically begins with vague, poorly localized visceral pain (often periumbilical or generalized) that later localizes to the right lower quadrant as the parietal peritoneum becomes inflamed. The described migration of pain to the lower right side reflects this progression and is a key assessment clue used in ED triage and nursing assessment. Diffuse abdominal pain for days is less specific and can suggest gastroenteritis or other generalized intra-abdominal processes. Persistent pain only above the umbilicus for a day does not match the typical localization pattern expected as appendiceal inflammation advances.

Question 38

An 11-month-old infant with neonatal chronic lung disease (bronchopulmonary dysplasia) and a tracheostomy experiences a decline in oxygen saturation from 97% to 88%. He appears anxious, and his heart rate is 180 beats/minute. Which nursing intervention is most appropriate?

Accepted Answer

Answer reason: An acute drop in SpO2 with anxiety and marked tachycardia in a tracheostomized infant most strongly suggests airway obstruction from retained secretions or a mucus plug. The fastest, highest-yield nursing action is to restore airway patency by suctioning, which directly addresses the most common reversible cause of sudden hypoxemia in a trach patient. Simply turning up oxygen can mask ongoing obstruction and delay effective ventilation, so it is not the best first action when obstruction is suspected. Changing the tube is more invasive and typically reserved for suspected tube dislodgement/occlusion not relieved by suction, while obtaining an ABG is diagnostic and delays immediate airway management.

Question 39

A client who developed a fat embolism is receiving 100% FIO2 on a mechanical ventilator and continues to be hypoxic. What is the most important intervention?

Accepted Answer

Answer reason: Refractory hypoxemia on 100% oxygen suggests severe V/Q mismatch or shunt with alveolar collapse, where increasing oxygen concentration alone will not meaningfully improve PaO2. PEEP recruits and splints alveoli open, increases functional residual capacity, and improves oxygenation by reducing intrapulmonary shunting—key in fat embolism–related acute lung injury/ARDS physiology. Increasing FiO2 further is not possible because the client is already at 100%. Beta-blockers and diuretics do not address the primary gas-exchange problem and can worsen hemodynamics or volume status without improving oxygenation.

Question 40

The nurse has just completed an assessment of a client who has suffered a head injury. During the assessment, the client consumed three glasses of water. Additionally, the nurse noted that the client’s output of a large amount of dilute urine with a specific gravity of less than 1.005. The nurse is aware that the client is at risk for which condition?

Accepted Answer

Answer reason: Low ADH causes inability to concentrate urine, producing large volumes of very dilute urine with a low specific gravity (

Question 41

The client, who delivered a 4200-g baby 4 hours ago, continues to have bright red, heavy vaginal bleeding. The nurse assesses the client's fundus and finds it to be firm and midway between the symphysis pubis and umbilicus. What should the nurse do next?

Accepted Answer

Answer reason: Heavy, bright-red postpartum bleeding with a firm, appropriately positioned fundus suggests the uterus is contracted, making uterine atony less likely and pointing instead to genital tract trauma (eg, lacerations) as the bleeding source. A large infant (macrosomia) increases the risk of lacerations and uterine overdistention-related complications, so ongoing heavy bleeding requires prompt evaluation. The priority action is to escalate care for a focused inspection of the cervix/vagina/perineum and management of possible lacerations. Giving uterotonics targets atony and is not the best next step when the fundus is already firm; simply monitoring or documenting as normal is unsafe with continued heavy bleeding.

Question 42

The child with a bum injury has had a skin graft. During the child’s dressing change, the new nurse asks the experienced nurse why the skin appears lattice-like and is not smooth like the unburned areas of the child’s body. Which is the experienced nurse’s best response?

Accepted Answer

Answer reason:  Meshed split-thickness grafts are commonly used in burn care to expand a limited donor site to cover a larger wound surface. The meshing creates a characteristic “lattice” pattern that can be visible during early healing and is an expected postoperative finding. This explanation directly addresses the appearance as a normal consequence of the grafting technique rather than a complication. Cadaver allograft is typically temporary and does not produce this characteristic pattern simply from freezing, making that distractor less accurate.

Question 43

A hospitalized client is experiencing hypoxia. The physician orders continuous positive airway pressure (CPAP) per face mask. The family is concerned and questions the nurse as to why the client needs the mask. What is the most appropriate response by the nurse?

Accepted Answer

Answer reason:  CPAP delivers a continuous positive pressure that functions like PEEP, increasing end-expiratory pressure to recruit alveoli and improve oxygenation. In hypoxia from alveolar collapse or poor ventilation-perfusion matching, keeping alveoli open increases functional residual capacity and reduces intrapulmonary shunting. This is the most accurate family-friendly explanation of the therapeutic purpose of CPAP. A common misconception is that the mask’s main role is delivering a specific high oxygen percentage, but the key benefit is pressure-based alveolar recruitment rather than guaranteed 100% FiO2.

Question 44

The nurse is caring for a 10-year-old client with advanced Duchenne muscular dystrophy (DMD). Which of the following would be a priority for the nurse to include in the plan of care?

Accepted Answer

Answer reason: Advanced DMD causes progressive weakness of respiratory muscles, leading to ineffective cough, secretion retention, atelectasis, and pneumonia, so early identification of respiratory compromise is the highest safety priority. Monitoring for cough changes helps detect reduced airway clearance and developing infection before hypoventilation or respiratory failure occurs. While constipation and nutrition are common issues, they are not as immediately life-threatening as declining ventilation and airway protection. Range-of-motion helps prevent contractures but does not address the most urgent risk in advanced disease, which is respiratory deterioration.

Question 45

The nurse is assessing a client with bipolar affective disorder and is a manic episode. Which symptom requires the nurse’s immediate attention?

Accepted Answer

Answer reason: This finding signals an immediate risk to airway/breathing/circulation stability and requires prompt nursing action (structured environment, fluids/calorie support, monitoring, and possible medication/containment). The other options reflect common manic behaviors (grandiosity, pressured speech, disinhibition) but are less immediately life-threatening unless they escalate to direct self-harm or violence. Prioritization in psychiatric care still follows safety and physiologic needs first.

Question 46

The nurse cares for a client with osteoarthritis, emphysema, and Raynaud phenomenon. Which findings are expected?

Accepted Answer

Answer reason: This finding is therefore directly expected in a client with Raynaud. Osteoarthritis more classically causes brief morning stiffness and pain that worsens with use rather than isolated digital numbness, and joint hyperextension is more typical of connective-tissue laxity than OA. Emphysema can present with chronic cough in some patients, but the most specific hallmark among the options that clearly matches one of the listed diagnoses is the digital coldness and numbness of Raynaud.

Question 47

The nurse is assessing a patient complaining of chest pain. Which description of the pain would lead the nurse to suspect pericarditis?

Accepted Answer

Answer reason: A central/retrosternal sharp pain that is position and breathing related aligns with this inflammatory mechanism. In contrast, a tearing pain radiating to the back is more concerning for aortic dissection, and arm-radiating pressure-like discomfort is more typical of myocardial ischemia. Also, pericarditis pain usually improves when sitting up and leaning forward rather than when lying down, making that distractor unsafe.

Question 48

The nurse is applying a nonrebreather mask for a hypoxic client admitted with carbon monoxide poisoning. Which intervention by the nurse is correct?

Accepted Answer

Answer reason: Keeping the one-way valves closed on inhalation and open on exhalation supports this design and helps maximize oxygen delivery, which is critical in carbon monoxide poisoning to displace CO from hemoglobin. The reservoir bag should not fully collapse with inhalation; it should remain partially inflated to ensure an adequate oxygen reservoir. Flow rates of 5–8 L/min are too low for a nonrebreather; inadequate flow can collapse the reservoir bag and dilute delivered oxygen, delaying effective treatment.

Question 49

A 70-year-old patient with a history of chronic obstructive pulmonary disease (COPD) is admitted to the hospital with an acute exacerbation. The patient is on 2 liters of oxygen via nasal cannula. Which of the following findings would indicate the need for immediate intervention by the nurse?

Accepted Answer

Answer reason: This indicates inadequate cerebral oxygenation/ventilation despite supplemental oxygen and requires rapid assessment (ABGs, ventilation status) and escalation of respiratory support. In contrast, an SpO2 around 88% can be an acceptable target range in COPD to avoid worsening CO2 retention, and mild tachypnea (RR 24) may be expected in an exacerbation. Accessory muscle use signals increased work of breathing, but mental status changes suggest decompensation and demand the most immediate action.

Question 50

A client with emphysema requires oxygen therapy. How should the nurse administer oxygen therapy to this client?

Accepted Answer

Answer reason: COPD/emphysema clients are at risk for oxygen-induced hypercapnia and V/Q mismatch, so oxygen should be titrated to a safe target rather than given at arbitrary fixed flow limits. A target saturation around 88–92% is commonly recommended, and aiming for at least 88% supports adequate tissue oxygenation while minimizing risk of CO2 retention. Flow rates and delivery devices should be adjusted based on measured SpO2/ABGs and the provider’s order, not solely on comfort or dyspnea perception. A fixed maximum L/min is not universally correct because required flow varies by device and patient response. Adjusting oxygen based on dyspnea alone is unsafe because dyspnea is subjective and may not correlate with oxygenation or ventilation status.

Train with a large NCLEX question bank and jump into a full exam-style simulator

Alterations in Body Systems NCLEX Practice Test

Continue Learning