Question 1

A patient arrives at the emergency department with complaints of increased swelling in the legs. The nurse suspects right sided heart failure and would most likely assess what other findings in this patient?

Accepted Answer

Answer reason: This leads to fluid backing up into the liver and splanchnic circulation, producing hepatomegaly and ascites/abdominal distension along with dependent edema. In contrast, orthopnea and prominent shortness of breath are more characteristic of left-sided failure with pulmonary congestion. Hypotension and dizziness can occur in advanced low-output states but are not the most likely associated findings when the presentation emphasizes peripheral edema from right-sided congestion.

Question 2

A 16-year old patient with cystic fibrosis is admitted with increased shortness of breath and possible pneumonia. Which nursing activity is most important to include in the patient's care?

Accepted Answer

Answer reason: The key principle in cystic fibrosis with suspected pneumonia is prioritizing airway clearance to improve ventilation and gas exchange. Thick, tenacious secretions obstruct airways and promote atelectasis and infection, so scheduled chest physiotherapy with postural drainage directly targets the most immediate physiologic threat. Allowing the patient to self-determine aerosol treatments risks missed bronchodilator/mucolytic doses and worsening obstruction. Private room placement and sleep promotion may be supportive, but they do not address the urgent need to mobilize secretions and relieve dyspnea.

Question 3

A client with arterial disease has intermittent claudication at rest. The client communicates that even the weight of bed sheets is uncomfortable on the lower legs. The client and the nurse discuss ways to prevent pain related to this disease symptom. Which measure does the nurse recommend?

Accepted Answer

Answer reason: ” Peripheral arterial disease pain at rest reflects critically reduced tissue perfusion, so interventions should focus on improving arterial blood flow and reducing vasoconstriction. Nicotine causes vasoconstriction and promotes atherosclerotic progression, directly worsening ischemia and claudication/rest pain; stopping smoking is one of the most effective risk-reduction measures. Compression stockings are typically used for venous disease and can further impair arterial circulation in PAD. Elevating the legs above the heart decreases arterial perfusion pressure to the feet and can worsen ischemic pain; clients with PAD often obtain relief by keeping legs dependent.

Question 4

Which of the following is a sign of hypoxia?

Accepted Answer

Answer reason: This finding reflects inadequate oxygenation and is a classic late sign that warrants urgent assessment and intervention. Mild tachypnea (22/min) can occur with many conditions (pain, anxiety, fever) and is not specific for tissue hypoxia by itself. Sitting upright is a compensatory position to ease breathing but is not a direct physiologic sign, and the listed blood pressure is within normal range and does not indicate oxygenation status.

Question 5

A patient with pulmonary emboli complains of pain, dyspnea, and a fear of dying. Which of the following interventions would MOST likely help to reduce the patient’s anxiety level?

Accepted Answer

Answer reason: Supplemental oxygen improves arterial oxygen saturation, reduces dyspnea work of breathing, and often rapidly decreases panic symptoms. Pain medication may help discomfort but does not directly address impaired gas exchange, which is the most immediate problem in PE-related distress. Listening therapeutically can support coping, but in acute respiratory compromise, stabilizing oxygenation is the most effective first step to reduce anxiety.

Question 6

A 1-month-old infant is brought to the pediatrician’s office. His mother states that he’s fussy and cries as if in pain. He’s tolerating normal amounts of formula, gaining weight, and having episodes of paroxysmal abdominal cramping after feedings. These signs and symptoms indicate that the infant most likely has which condition?

Accepted Answer

Answer reason: Infantile colic typically presents in the first few months of life with episodes of intense, paroxysmal crying and apparent abdominal discomfort, often after feeding. Importantly, the infant continues to feed well, gain weight, and shows no signs of systemic illness. Intussusception usually presents later with severe episodic pain and “currant jelly” stools, pyloric stenosis causes projectile vomiting and poor weight gain, and meconium ileus is seen in newborns with cystic fibrosis and presents with failure to pass meconium.

Question 7

Which statement by the father of an 8-year-old boy with Duchenne’s muscular dystrophy indicates that he has realistic expectations about the course of the disease?

Accepted Answer

Answer reason: Duchenne muscular dystrophy is a progressive, degenerative neuromuscular disorder characterized by gradual muscle weakness that leads to loss of ambulation, typically in late childhood. This statement reflects an accurate understanding of disease progression. Corticosteroids may slow progression but do not prevent degeneration, surgery does not restore the ability to walk, and life expectancy is reduced due to respiratory and cardiac complications.

Question 8

A client is admitted to the emergency department with shortness of breath, tachypnea, and a productive cough with greenish sputum. The nurse suspects pneumonia. Which action should the nurse prioritize when planning care for this client?

Accepted Answer

Answer reason: Providing supplemental oxygen supports gas exchange and rapidly improves oxygen delivery to tissues while further assessment and treatments are arranged. Deep breathing and coughing help mobilize secretions but are not the first action if the client is already short of breath and tachypneic. Antivirals are not routine for typical bacterial pneumonia suggested by greenish sputum, and analgesics address comfort but do not stabilize oxygenation.

Question 9

The nurse is caring for a patient with a asthma. Which of the following findings are most concerning?

Accepted Answer

Answer reason: Wheezing reflects narrowed airways and increasing work of breathing, making it a key concerning sign that the patient may be moving into moderate or severe bronchoconstriction even before oxygen saturation drops. A SpO2 of 96% and a respiratory rate of 22 can be consistent with mild distress or early compensation and are less specific for significant obstruction. Being able to speak in complete sentences generally suggests the patient is not in severe respiratory distress at that moment. The most dangerous trend in asthma is worsening obstruction that can progress rapidly, so abnormal breath sounds indicating bronchospasm warrant prompt assessment and treatment escalation.

Question 10

A 2-year-old child with confirmed influenza is hospitalized for respiratory distress. Which assessment finding requires the most immediate nursing action?

Accepted Answer

Answer reason: Retractions and nasal flaring indicate the child is using accessory muscles to maintain ventilation and can decompensate quickly due to limited pediatric respiratory reserve. Compared with a pulse oximetry of 92% (mild hypoxemia that still requires intervention), visible increased work of breathing is a more urgent indicator of clinical deterioration. Fever and decreased intake are expected with influenza and are important but not as immediately life-threatening as worsening respiratory distress.

Question 11

A client has a tentative diagnosis of urethritis. The nurse would assess the client for which manifestation of the disorder?

Accepted Answer

Answer reason: Pain or burning with urination is expected because inflamed urethral mucosa is irritated by urine flow. Urethral/penile discharge is a classic associated finding in infectious urethritis (e.g., gonococcal or chlamydial), reflecting mucopurulent exudate. Findings like proteinuria are more suggestive of renal involvement, and urgency/pyuria can occur with lower UTIs but are less characteristic than discharge for urethritis. Therefore, the combination of dysuria with penile discharge best matches urethritis manifestations.

Question 12

The ICU nurse is taking care of a client who sustained a head injury due to a motorcycle accident. In the morning, the client is responsive to pain and assumes a decorticate position. After 4 hours, which assessment would indicate to the nurse that the client needs immediate intervention?

Accepted Answer

Answer reason: Progression from decorticate (flexor) posturing to decerebrate (extensor) posturing indicates worsening neurologic status and potential brainstem involvement from rising intracranial pressure or herniation. Extensor posturing to painful stimulus is a late, ominous sign and requires immediate action to protect airway/ventilation, rapidly reassess neuro status, and notify the provider/activate ICP management. Purposeful movement to pain or obeying commands reflects improvement rather than deterioration. Nonpurposeful flailing can be abnormal but is less classically indicative of dangerous downward neurologic progression than new extensor posturing.

Question 13

Which of the following foods would the nurse eliminate from the diet of a client with alcohol withdrawal?

Accepted Answer

Answer reason: Caffeine is a CNS stimulant that can worsen restlessness, palpitations, and sleep disruption, thereby aggravating withdrawal symptoms and complicating stabilization. Eliminating caffeinated beverages supports calmer sensorium, improved sleep, and easier monitoring of true withdrawal severity. In contrast, non-caffeinated, nutrient-containing fluids like milk or juice help with hydration and caloric support without increasing sympathetic stimulation.

Question 14

A child is admitted to the hospital with an acute asthma exacerbation. Which assessment finding does the nurse identify as most concerning?

Accepted Answer

Answer reason: Markedly decreased bilateral breath sounds suggest “silent chest,” meaning airflow is so limited that wheezing may diminish or disappear despite worsening obstruction. This finding signals rapid fatigue and poor ventilation, requiring urgent escalation (aggressive bronchodilation, oxygen, and possible ventilatory support). Nasal flaring, accessory muscle use, and wheezing reflect increased work of breathing but still imply there is appreciable airflow compared with a silent chest.

Question 15

Dyspnea, cough, expectoration, weakness, and edema are classic signs and symptoms of which of the following conditions?

Accepted Answer

Answer reason: In restrictive cardiac disorders (classically restrictive cardiomyopathy), impaired ventricular filling causes elevated filling pressures, leading to pulmonary venous congestion (dyspnea, cough with sputum) and right-sided congestion (dependent edema, fatigue/weakness). Pericarditis more typically presents with pleuritic chest pain, friction rub, and positional pain relief rather than prominent edema and expectoration. Hypertension can contribute to heart failure over time, but it is a risk factor/etiology rather than the best single condition that directly explains this classic combined pulmonary-plus-edema presentation.

Question 16

An oxygenated delivery system is prescribed for a client with COPD to deliver a precise oxygen concentration. Which of the following types of oxygen delivery systems would the nurse anticipate to be prescribed?

Accepted Answer

Answer reason: A Venturi mask is a high-flow device that uses an air-entrainment system to deliver a fixed, predictable oxygen concentration (e.g., 24%–50%) regardless of the patient’s breathing pattern. In contrast, face tents and tracheostomy collars primarily provide humidification and deliver less reliable, variable FiO2. An aerosol mask is generally used for humidified oxygen delivery and is not the standard choice when the key requirement is tightly controlled FiO2.

Question 17

A 62-year-old client with chronic obstructive pulmonary disease (COPD) is admitted with worsening shortness of breath, productive cough, and confusion. Arterial blood gas (ABG) results are: • pH: 7.28 • PaCO₂: 65 mm Hg • HCO₃⁻: 26 mEq/L • PaO₂: 55 mm Hg The client is on 2 L/min oxygen via nasal cannula. Which intervention should the nurse implement first?

Accepted Answer

Answer reason: Upright positioning increases lung expansion, improves diaphragmatic excursion, and can reduce work of breathing, which is crucial in acute hypercapnic respiratory acidosis with hypoxemia (pH 7.28, PaCO2 65, PaO2 55) and altered mentation. Escalating oxygen flow in COPD can worsen CO2 retention in some patients and should be titrated to a target SpO2 rather than reflexively increased. While the provider must be notified and NIPPV may be needed, implementing positioning is the fastest first action that can be done while preparing for further escalation.

Question 18

Jomarick is diagnosed with FVD; which of the following nursing diagnoses might apply to his condition?

Accepted Answer

Answer reason: Lower preload decreases stroke volume and therefore lowers overall cardiac output, leading to signs like hypotension, tachycardia, weak pulses, and poor perfusion. This is the most direct nursing diagnosis capturing the primary hemodynamic consequence of volume depletion. “Increased cardiac output” conflicts with the expected physiology, and “vomiting” or “altered urinary elimination” may be causes/associated findings but are not the core systemic impact of FVD.

Question 19

Which assessment finding calls for the most immediate further assessment or interventions?

Accepted Answer

Answer reason: Central cyanosis indicates inadequate oxygenation and possible respiratory failure or severe hypoxemia, which is an immediate threat to airway/breathing. This finding warrants rapid assessment of respiratory effort, pulse oximetry/ABG as indicated, and prompt oxygen support per protocol. In contrast, erythema, hyperpigmented spotting, or jaundice can reflect dermatologic or hepatic issues that usually do not require the same level of immediate emergency response unless accompanied by other instability signs. Prioritization follows ABCs, making suspected hypoxia the most urgent.

Question 20

Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. Which is the nurse’s best action?

Accepted Answer

Answer reason: The appropriate nursing response is to recognize and trend the assessment data, documenting it and continuing ongoing monitoring for abdominal distention, pain, nausea/vomiting, and ability to tolerate enteral intake. Giving a laxative is inappropriate because ileus is not constipation and stimulating the bowel can worsen discomfort or risk complications if obstruction is present. Increasing IV fluids is guided by burn resuscitation parameters (urine output, vitals, hemodynamics) rather than bowel sounds alone, and repositioning does not address the underlying physiologic cause.

Question 21

You are performing an assessment of a five-month-old who has been admitted for Respiratory Syncytial Virus (RSV). This morning, she was resting quietly on 1L nasal cannula with mild intercostal retractions. Which of the following changes would warrant immediate investigation by the provider?

Accepted Answer

Answer reason: Increasing retractions indicate escalating respiratory distress and fatigue, and new/worsening wheeze suggests progression of lower-airway obstruction and air trapping that may require prompt escalation (e.g., higher oxygen/respiratory support, suctioning, bronchodilator trial per protocol, or further evaluation). A transient oxygen saturation dip during coughing can occur briefly from airway irritation and is less concerning if it promptly recovers. Low-grade fever and slower feeding can be expected in RSV and warrant monitoring, but they are not as immediately threatening as increased respiratory effort.

Question 22

SITUATION: A nurse is caring for a client admitted with acute cholecystitis. Which of the following is the most appropriate nursing intervention to include in the plan of care?

Accepted Answer

Answer reason: Keeping the client NPO reduces biliary stimulation, supports symptom control, and prepares for potential procedures (e.g., imaging with contrast, surgery) while IV fluids/analgesics are managed. Heat to the RUQ is not routinely recommended because it can increase local vasodilation and may exacerbate inflammation or mask worsening symptoms. A high-fat diet triggers gallbladder contraction, and lying flat commonly increases discomfort; upright or semi-Fowler positioning is typically better tolerated.

Question 23

Nurse Olivia is assessing Sarah, a 65-year-old patient who has been complaining of weight gain, nausea, and a decrease in urine output. Which cardiac condition should Nurse Olivia most strongly consider based on these symptoms?

Accepted Answer

Answer reason: This explains weight gain from edema/ascites and decreased renal perfusion with activation of RAAS, producing reduced urine output and further sodium/water retention. Hepatic and gastrointestinal congestion can cause anorexia, abdominal discomfort, and nausea. In contrast, left-sided failure more typically presents with pulmonary congestion symptoms such as dyspnea, orthopnea, and crackles rather than predominant systemic fluid overload findings.

Question 24

A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority?

Accepted Answer

Answer reason: Using ABC priorities, oxygenation status must be assessed first because hypoxemia can rapidly lead to cardiac arrest and secondary spinal cord injury. Continuous pulse oximetry provides fast, actionable information to detect evolving respiratory compromise requiring supplemental oxygen, ventilatory support, or escalation of care. Neurologic assessment is crucial but comes after stabilizing ventilation and perfusion, while bladder distension and emotional response are lower-priority needs in the acute phase.

Question 25

Medical management of the client with diverticulitis should include which of the following treatments?

Accepted Answer

Answer reason: Diverticulitis is an acute inflammation/infection of diverticula, so medical management centers on treating infection and preventing complications such as abscess, perforation, and peritonitis. Antibiotics are indicated when diverticulitis is suspected/confirmed to reduce bacterial load and control the infectious process, often alongside bowel rest and supportive care. Increasing fiber is generally a prevention strategy for diverticulosis or used after the acute episode resolves, not during acute diverticulitis. Reducing fluids and intentionally increasing intra-abdominal pressure can worsen constipation/straining and raise risk of worsening inflammation or complications.

Question 26

Which of the following actions is the first priority of care for a client exhibiting signs and symptoms of coronary artery disease?

Accepted Answer

Answer reason: Myocardial ischemia in coronary artery disease reflects an oxygen supply–demand imbalance, so the immediate nursing priority is to improve oxygen delivery and reduce cardiac workload to prevent infarction and dysrhythmias. Interventions that increase oxygen availability (e.g., rest, positioning, supplemental oxygen if indicated) address the most time-sensitive physiologic threat. Giving nitroglycerin can be appropriate, but it is a specific medication action that follows rapid assessment and broader stabilization aimed at oxygenation and perfusion, and it may be contraindicated in hypotension or recent PDE-5 inhibitor use. Anxiety reduction and teaching are supportive measures but do not address the immediate risk of ongoing myocardial hypoxia.

Question 27

Jeron is admitted to the hospital due to bacterial pneumonia. He is febrile, diaphoretic, and has shortness of breath and asthma. Which goal is the most important for the client?

Accepted Answer

Answer reason: Bacterial pneumonia plus asthma increases risk for impaired gas exchange and ventilation-perfusion mismatch, making oxygenation the immediate, life-sustaining goal. Fever and diaphoresis also raise metabolic demand and can worsen oxygen consumption, further elevating the urgency of ensuring adequate oxygen delivery. Teaching and pain control are important but are secondary once oxygenation is stabilized, and preventing fluid volume excess is not the primary acute threat compared with compromised breathing.

Question 28

Following a generalized seizure, the nurse can expect the client to?

Accepted Answer

Answer reason: Somnolence and a strong desire to sleep are therefore expected findings immediately after the event. In contrast, true inability to move extremities suggests a focal postictal deficit (Todd paralysis) and is not the typical expectation after generalized seizures. Blood pressure more often rises transiently during/after convulsions due to sympathetic activation rather than dropping as a consistent post-seizure pattern.

Question 29

The nurse anticipates using postural drainage as a treatment modality for which condition?

Accepted Answer

Answer reason: This therapy is classically indicated in conditions with chronic, tenacious mucus and impaired mucociliary clearance. In cystic fibrosis, dehydrated secretions and recurrent obstruction make airway clearance techniques a core, routine treatment. In contrast, epiglottitis and foreign body aspiration are airway emergencies where positioning and suction/airway management take priority rather than secretion-mobilizing maneuvers.

Question 30

A newly admitted client is suspected to have avian influenza (“bird flu”) due to increasing dyspnea and dehydration. Which of these prescribed actions will the nurse implement first?

Accepted Answer

Answer reason: High-concentration supplemental oxygen is an immediate intervention to improve oxygenation while further assessment and treatments are initiated. Antiviral therapy and specimen collection are important but do not address the immediate threat of impaired gas exchange. IV fluids can support dehydration, but they are secondary to stabilizing respiratory status and ensuring adequate tissue oxygen delivery.

Question 31

When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result?

Accepted Answer

Answer reason: PaCO2 of 30 mm Hg indicates hypocapnia from hyperventilation, which causes cerebral vasoconstriction and decreases cerebral blood volume. In acute intracranial hemorrhage/hematoma, controlled reduction of PaCO2 can transiently lower ICP and help prevent secondary brain injury. This finding does not by itself indicate poor oxygenation (that would be assessed by PaO2/SaO2), and it is the opposite of alveolar hypoventilation, which would raise PaCO2. While excessive/prolonged hypocapnia can compromise cerebral perfusion, the best description of this isolated ABG value in this context is that it can be therapeutically appropriate for ICP control.

Question 32

SITUATION: A client diagnosed with colon cancer is being prepared for palliative surgery to correct an intestinal obstruction. The nurse understands that palliative surgery is?

Accepted Answer

Answer reason: Palliative surgery is guided by the principle of improving comfort and quality of life when cure is not the goal. In advanced colon cancer with obstruction, surgery may bypass or decompress the bowel to reduce pain, nausea/vomiting, and inability to pass stool or gas, thereby improving function. This contrasts with curative surgery, which aims to remove all malignant tissue for disease eradication. It is also distinct from diagnostic biopsy procedures and cosmetic/reconstructive operations focused primarily on appearance.

Question 33

Nurse Gonzalez is evaluating Joe, a 13-year-old boy who has been diagnosed with pneumococcal pneumonia. She is conducting a thorough assessment to monitor his condition closely. Which symptom is Nurse Gonzalez most likely to expect and assess in Joe as part of her evaluation?

Accepted Answer

Answer reason: Pneumococcal pneumonia commonly causes pleural irritation and inflammation, which produces sharp, localized pain that can worsen with deep inspiration or coughing (pleuritic pain). This finding is more characteristic of bacterial pneumonia in older children/adolescents than a “mild cough,” which can undersell the expected respiratory symptom burden. A “bulging fontanel” is a sign of increased intracranial pressure in infants and is not applicable to a 13-year-old. Fever may occur, but chest pain is a more distinguishing symptom to anticipate and assess when evaluating for pleural involvement and respiratory compromise.

Question 34

A 12-year-old boy was admitted to the hospital two days ago due to hyperthermia. His attending nurse, Dennis, is quite unsure about his plan of care. Which of the following nursing interventions should be included in the care plan for the client?

Accepted Answer

Answer reason: Lowering ambient temperature is a safe, immediate, noninvasive nursing intervention that supports conductive/convective heat loss and complements other cooling measures. Restricting fluids is generally unsafe because fever and increased insensible losses raise hydration needs, so limiting intake can worsen volume depletion. Routine axillary checks q4h may be insufficient and less accurate than core/other routes when temperature is significantly elevated, and antiemetics are not indicated unless nausea/vomiting is present and ordered.

Question 35

A client has a cervical spine injury at the level of C5. Which of the following conditions would the nurse anticipate during the acute phase?

Accepted Answer

Answer reason: In the acute phase, edema and evolving neurologic deficits can worsen respiratory mechanics, so patients with injuries around C5 are at significant risk for ventilatory failure and may require intubation with ventilatory support. This expectation aligns with early priorities of maintaining oxygenation/ventilation and preventing hypoxia-related secondary injury. Findings like absent corneal reflex or decerebrate posturing point more toward severe brainstem/brain injury rather than an isolated C5 spinal cord injury. Hemibody movement deficits are more typical of cerebral lesions (e.g., stroke) than a cervical cord injury pattern.

Question 36

In assessing a patient, the nurse understands that an early sign of hypoxemia is?

Accepted Answer

Answer reason: Anxiety, restlessness, and agitation can occur as compensatory sympathetic activation and cerebral oxygen delivery drop. Cyanosis is a relatively late and often unreliable sign because it depends on the amount of deoxygenated hemoglobin and may be absent in anemia or with supplemental oxygen. Clubbing reflects chronic hypoxemia over time, and hypotension is not an early hallmark of isolated low arterial oxygen levels.

Question 37

When obtaining the health history from a male client with retinal detachment, the nurse expects the client to report?

Accepted Answer

Answer reason: Retinal detachment commonly presents with photopsia (brief flashes) and new-onset floaters due to vitreoretinal traction and cells or blood in the vitreous. These symptoms reflect a mechanical problem at the retina rather than systemic or infectious/inflammatory illness. Headache, nausea, and eye redness are more suggestive of acute angle-closure glaucoma, which is a different emergency with a painful red eye. Diplopia and a driving accident history are not typical hallmark history findings for retinal detachment.

Question 38

A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed?

Accepted Answer

Answer reason: The safest approach is to start low-flow oxygen and titrate to the lowest dose that maintains adequate oxygenation rather than giving high flows routinely. A maximum of 2 L/min by nasal cannula is a common exam guideline to reduce the risk of knocking out hypoxic drive and causing CO2 narcosis. Higher flow rates such as 6–10 L/min can rapidly increase PaO2, worsen V/Q mismatch and the Haldane effect, and precipitate acute hypercapnic respiratory failure. Ongoing monitoring of SpO2/ABGs and mental status is essential while titrating therapy.

Question 39

A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to?

Accepted Answer

Answer reason: Pursed-lip breathing prolongs exhalation and creates a mild positive expiratory pressure, which helps prevent small-airway collapse during exhalation. This improves alveolar ventilation, decreases air trapping, and enhances removal of retained gas, particularly in obstructive conditions like COPD. As trapped gas is reduced, ventilation-perfusion matching and dyspnea typically improve. A common misconception is that its main goal is increasing oxygen intake; oxygenation may improve secondarily, but the primary physiologic effect is facilitating more complete exhalation and reducing CO2 retention.

Question 40

A nurse is caring for a male client with acute respiratory distress syndrome. Which of the following would the nurse expect to note in the client?

Accepted Answer

Answer reason: This creates significant ventilation-perfusion mismatch and intrapulmonary shunting, producing hypoxemia that is often refractory to supplemental oxygen, so arterial oxygen tension drops. A decreased respiratory rate is not expected because patients typically become tachypneic from increased work of breathing. Elevated arterial oxygen tension would contradict the fundamental hypoxemic respiratory failure seen in ARDS, while pallor is nonspecific and not a defining finding.

Question 41

For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to?

Accepted Answer

Answer reason: Increased ICP can be rapidly influenced by changes in PaCO2 because CO2 is a potent cerebral vasodilator. Lowering PaCO2 via controlled ventilation causes cerebral vasoconstriction, reducing cerebral blood volume and helping decrease ICP in acute deterioration. This is a time-sensitive supportive goal used while definitive causes are addressed, with careful avoidance of excessive hypocapnia that could reduce cerebral perfusion. A common distractor is focusing only on oxygenation; although avoiding hypoxemia is essential, manipulating CO2 has the more direct short-term effect on ICP.

Question 42

A client is admitted with a spinal cord injury at the level of T12. He has limited movement of his upper extremities. Which of the following medications would be used to control edema of the spinal cord?

Accepted Answer

Answer reason: High-dose corticosteroids reduce inflammatory mediator activity and capillary permeability, which can decrease spinal cord swelling early after injury. This directly targets the pathophysiologic cause of cord edema rather than just promoting general diuresis. A loop diuretic may reduce overall fluid volume but does not reliably treat localized cord inflammation/edema, and acetazolamide and sodium bicarbonate are not indicated for spinal cord edema control.

Question 43

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?

Accepted Answer

Answer reason: Autonomic dysreflexia is triggered by noxious stimuli below the level of injury, most commonly bladder distention from urinary retention or a blocked/overfull bladder. Extending intermittent catheterization intervals increases the risk of bladder overfilling, making recurrent episodes more likely rather than preventing them. In contrast, bowel programs, avoiding skin irritation from wrinkles, and preventing pressure on the limbs reduce common precipitating stimuli such as fecal impaction and pressure injury. The safest prevention strategy is to ensure regular, adequate bladder emptying and promptly address urinary obstruction.

Question 44

The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?

Accepted Answer

Answer reason: Tachypnea, often with shallow respirations, is a common physiologic response when hemoglobin is insufficient. Elevated blood pressure is not a typical direct manifestation of anemia and is more suggestive of cardiovascular risk or stress. A pink complexion is less consistent with anemia, which more often causes pallor due to reduced oxyhemoglobin in peripheral tissues.

Question 45

The nurse is caring for a patient with acute respiratory failure and identifies "Risk for Ineffective Airway Clearance" as a nursing diagnosis. A nursing intervention relevant to this diagnosis is?

Accepted Answer

Answer reason: Maintaining airway patency and optimizing ventilation are immediate priorities when airway clearance is at risk. Elevating the head of the bed promotes lung expansion, improves diaphragmatic excursion, and enhances mobilization of secretions, thereby supporting cough effectiveness and reducing aspiration risk. This is a direct, bedside nursing intervention that can be implemented promptly without additional provider orders. In contrast, venous thromboembolism prophylaxis addresses clot prevention rather than airway clearance, and sedation can depress cough and respiratory drive, potentially worsening secretion retention. Turning every 2 hours helps prevent pressure injuries and can aid ventilation but is less directly targeted to airway clearance than positioning the patient upright.

Question 46

A newly admitted client has sickle cell crisis. He is complaining of pain in his head and hands. The nurse’s assessment findings include a pulse oximetry of 92. Assuming that all the following interventions are ordered, which should be done first?

Accepted Answer

Answer reason: O2 Sickle cell crisis causes vaso-occlusion and tissue hypoxia, so immediate support of oxygenation is the priority using ABCs. An SpO2 of 92% indicates impaired oxygenation, and supplemental oxygen can quickly improve arterial oxygen content and reduce further sickling triggered by hypoxemia. IV fluids are important to decrease blood viscosity and improve perfusion, but they do not address the most immediate threat if the client is hypoxic. Analgesia is essential for crisis management, yet treating pain does not correct the underlying oxygen deficit and is not the first step when oxygenation is compromised.

Question 47

A patient admitted to the hospital with myocardial infarction develops severe pulmonary edema. Which of the following symptoms should the nurse expect the patient to exhibit? Mark one answer?

Accepted Answer

Answer reason: Severe pulmonary edema from acute left ventricular failure causes alveolar flooding and impaired gas exchange, producing marked hypoxemia and an intense sensation of dyspnea. The expected clinical picture is extreme respiratory distress with tachypnea, orthopnea, and a feeling of suffocation. This is best captured by “air hunger,” which reflects the patient’s subjective struggle to breathe in the setting of acute pulmonary congestion. Slow, deep respirations suggest hypoventilation rather than acute fluid-overload respiratory compromise, and stridor points to upper-airway obstruction, not pulmonary edema.

Question 48

Which vital sign is the top nursing priority for a normal newborn infant?

Accepted Answer

Answer reason: Newborns are transitioning from placental gas exchange to independent lung function, making respiratory status the most immediate indicator of stability. Respiratory distress (tachypnea, retractions, grunting, nasal flaring, cyanosis) can be subtle early yet requires prompt intervention. Temperature is important, but its effects are typically less immediately life-threatening than compromised breathing, and blood pressure is not routinely the first priority vital sign in a normal newborn.

Question 49

Which clinical manifestation is expected upon initial assessment of a client with acute pancreatitis?

Accepted Answer

Answer reason: Early assessment findings most consistently reflect this pain pattern before later systemic complications evolve. Hypovolemic shock can occur from third spacing and capillary leak, but it is a severe complication rather than the most expected initial manifestation. Ascites is more characteristic of chronic liver disease or advanced pancreatic complications, and constipation is nonspecific and not a classic initial hallmark.

Question 50

Which subjective or objective assessment finding would the nurse expect to find in a client with severe aortic stenosis?

Accepted Answer

Answer reason: With exertion, systemic perfusion may drop, leading to presyncope or syncope—one of the classic severe aortic stenosis symptoms (along with angina and dyspnea). Bounding peripheral pulses are more consistent with aortic regurgitation and widened pulse pressure, not stenosis. The murmur of aortic stenosis is typically a systolic ejection murmur and the aortic component of S2 may be soft or absent rather than loud in severe disease.

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

Alterations in Body Systems NCLEX Practice Test

Continue Learning