Question 1

A client has been diagnosed with deep vein thrombosis (DVT). Which nursing intervention should take priority to reduce risk of complications?

Accepted Answer

Answer reason: Elevating the affected leg promotes venous return and reduces edema, helping prevent thrombus extension and pulmonary embolism. Pain relief and anticoagulant administration are important but not the immediate nursing priority for preventing complications.

Question 2

A G2P1 with a previous cesarean section due to obstructed labour comes for her first antenatal visit at 34 weeks' gestation. She is seeking advice about home delivery this time. What will be the most dangerous complication in her case if we allow her to deliver at home with an untrained birth attendant?

Accepted Answer

Answer reason: A prior cesarean scar places her at high risk of uterine rupture during labour, especially without skilled monitoring—this is the most life-threatening complication listed.

Question 3

Which one of the following clients is most likely to develop acute respiratory distress syndrome?

Accepted Answer

Answer reason: Long-bone fractures increase the risk of fat embolism, a well-known trigger for ARDS due to inflammatory damage to the alveolar-capillary membrane. The other options are less strongly associated with ARDS.

Question 4

What is the primary purpose of maintaining NPO status for six to eight hours before surgery?

Accepted Answer

Answer reason: Preoperative NPO keeps the stomach empty so that during anesthesia, when protective airway reflexes are depressed, the risk of regurgitation and aspiration pneumonia is minimized.

Question 5

A child with scoliosis has had a spica cast applied. Which action specific to the spica cast should be taken?

Accepted Answer

Answer reason: Body and spica casts can compress abdominal structures and lead to cast (mesenteric artery) syndrome; monitoring bowel sounds is a cast-specific action to detect GI compromise. The other options are general care for any patient with a cast.

Question 6

A client is admitted with a suspected gastrointestinal bleed. What assessment finding indicates a potential complication of this condition?

Accepted Answer

Answer reason: A GI bleed can progress to hypovolemia and shock. Hallmark findings include hypotension and tachycardia with decreased urine output. Thus, hypotension indicates a serious complication.

Question 7

The nurse is assessing a client immediately after an exploratory laparotomy. Which of the following nursing observations would relate to the complication of intestinal obstruction?

Accepted Answer

Answer reason: Intestinal obstruction typically presents with abdominal distention and crampy pain. Diarrhea is uncommon; ascites indicates another condition, and minimal bowel sounds are more consistent with postoperative ileus than with a mechanical obstruction. Therefore, a distended abdomen with pain best indicates obstruction.

Question 8

A client is recovering from a thyroidectomy. While monitoring the client's initial postoperative condition, which of the following should the nurse report immediately?

Accepted Answer

Answer reason: Post-thyroidectomy damage to the parathyroid glands can cause acute hypocalcemia; early signs are perioral numbness, paresthesia, and tetany, which signal risk for laryngospasm and seizures and require immediate reporting.

Question 9

The nurse is caring for a client admitted with acute laryngotracheobronchitis (LTB). Because of the possibility of complete airway obstruction, which of the following should the nurse have available?

Accepted Answer

Answer reason: LTB can cause sudden, complete airway obstruction. The priority is readiness to secure the airway; therefore, emergency intubation equipment must be immediately available.

Question 10

The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid?

Accepted Answer

Answer reason: Leukemia often causes thrombocytopenia, increasing bleeding risk. Flossing can injure gums and provoke bleeding. Patients should use an electric razor and maintain gentle oral care; no need to avoid oil- or cream-based soaps or salt specifically.

Question 11

The nurse is assessing a comatose client receiving gastric-tube feedings. Which of the following assessments requires an immediate response from the nurse?

Accepted Answer

Answer reason: A comatose client on gastric tube feedings is at high risk for aspiration. Newly decreased breath sounds in the right lower lobe suggest aspiration or atelectasis and threaten the airway and oxygenation, requiring immediate intervention. The other findings are not as emergent.

Question 12

The nurse is caring for a client with insulin-dependent diabetes mellitus. Which of the following initial assessment findings is MOST predictive of potential for impaired skin integrity?

Accepted Answer

Answer reason: Peripheral neuropathy causes a loss of protective sensation in the feet, so injuries and pressure go unnoticed, making it the strongest predictor of skin breakdown in diabetes.

Question 13

The nurse is caring for a child who has just returned from surgery following a tonsillectomy and adenoidectomy. Which of the following actions by the nurse is appropriate?

Accepted Answer

Answer reason: After a tonsillectomy, the priority is to detect hemorrhage; frequent swallowing can indicate bleeding. Monitoring swallowing is appropriate, while ice cream initially, supine positioning, and using a straw are contraindicated.

Question 14

The client is admitted following application of a cast for a fractured ulna. Which finding should be reported to the doctor?

Accepted Answer

Answer reason: Paresthesia signals neurovascular compromise or compartment syndrome after casting and requires immediate provider notification. Pain at the site is expected; warm fingers are a good sign of perfusion, and rapid pulses are nonspecific.

Question 15

The nurse is preparing to discharge a client following a trabeculoplasty for the treatment of glaucoma. The nurse should instruct the client to?

Accepted Answer

Answer reason: After glaucoma surgery, clients should protect the operative eye to prevent injury and complications. Washing the eye with shampoo, tub baths that risk water exposure, and early return to eye makeup increase the risk of contamination or irritation. Teaching clients to wear protective eyewear for an extended period is appropriate.

Question 16

The nurse is obtaining a history on an 80-year-old client. Which statement made by the client might indicate a potential for fluid and electrolyte imbalance?

Accepted Answer

Answer reason: Frequent laxative use in older adults can cause excessive fluid loss and electrolyte disturbances, especially hypokalemia, signaling a potential imbalance. The other statements do not directly indicate a risk for fluid or electrolyte imbalance.

Question 17

The nurse is monitoring a patient status post-epicardial pacing wire removal. The hospital protocol requires assessment for signs and symptoms of Beck's triad with each vital sign evaluation. The nurse understands the risk to the patient is?

Accepted Answer

Answer reason: Removal of epicardial pacing wires can cause bleeding into the pericardial space, leading to cardiac tamponade; Beck's triad (hypotension, JVD, muffled heart sounds) specifically indicates tamponade.

Question 18

The nurse is caring for a client with a tracheostomy. Which of the following items is essential to have at the bedside?

Accepted Answer

Answer reason: A spare inner cannula at the bedside allows immediate replacement if the cannula becomes obstructed, maintaining airway patency. Nasal cannula oxygen is ineffective for a tracheostomy; a humidifier is helpful but not critical in an emergency, and a brush is not essential equipment.

Question 19

What is the best action for the nurse to take when a postoperative patient reports severe pain despite receiving prescribed opioid analgesics?

Accepted Answer

Answer reason: Severe pain despite opioids can indicate a postoperative complication (e.g., bleeding, ischemia, compartment syndrome). The priority is to assess and identify the cause before administering more opioids or offering adjunctive measures.

Question 20

A 5-year-old child is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery?

Accepted Answer

Answer reason: After a tonsillectomy, frequent or constant swallowing is a classic sign of postoperative bleeding, a serious complication. A mild decrease in appetite and a low-grade fever can be expected; chest congestion is less specific.

Question 21

The client has recently returned from a thyroidectomy. Which of the following should the nurse keep at the bedside?

Accepted Answer

Answer reason: Post-thyroidectomy patients are at high risk for airway obstruction from edema or hemorrhage. Keeping a tracheotomy set at the bedside allows the rapid establishment of an airway if respiratory distress occurs. The other items do not address this immediate risk as effectively.

Question 22

A cataract extraction was performed on a client's right eye. What is the priority nursing care immediately postoperatively?

Accepted Answer

Answer reason: After cataract surgery, the priority is preventing increased intraocular pressure: avoid coughing and lying on the operated side. NPO is not required. The only safe immediate measure among the options is assisting with extremity ROM.

Question 23

Which of the following complications is of greatest concern when caring for a preoperative client with an abdominal aneurysm?

Accepted Answer

Answer reason: Before surgery for an abdominal aortic aneurysm, the most life-threatening complication is rupture, which can cause massive hemorrhage and shock. Hypertension, arrhythmias, or diminished pulses are concerns but not as immediately fatal as rupture.

Question 24

Which of the following responses from a 10-year-old patient with acute appendicitis is alarming?

Accepted Answer

Answer reason: In acute appendicitis, sudden relief of pain can signal perforation and impending peritonitis, an emergent complication. The other statements reflect expected feelings or nonspecific symptoms.

Question 25

Two hours after an appendectomy, a patient complains of a rapid heart rate and fever with abdominal and shoulder pain. What is the first step in management?

Accepted Answer

Answer reason: Tachycardia, fever, and referred shoulder pain soon after appendectomy suggest possible peritonitis from leakage or perforation. The nurse’s immediate priority is to maintain IV access and begin fluid resuscitation while notifying the surgeon for further evaluation.

Question 26

A client arrives from surgery following an abdominoperineal resection with a permanent ileostomy. What should be the priority nursing care during the postoperative period?

Accepted Answer

Answer reason: The immediate priority after abdominoperineal resection is to prevent perineal wound complications by promoting effective drainage. Ileostomies are not irrigated, a high-fiber diet is not appropriate early post-op, and electrolyte loss through the stoma cannot be stopped; rather, it is monitored and replaced.

Question 27

The home health nurse is visiting a 30-year-old client with sickle cell disease. Assessment findings include splenomegaly. What information obtained during the visit would cause the most concern? The client?

Accepted Answer

Answer reason: With splenomegaly and sickle cell disease, heavy physical work increases the risk of splenic trauma or rupture and can precipitate hypoxia and dehydration, triggering a sickle-cell crisis. This is more concerning than diet, occasional alcohol consumption, or mild fatigue.

Question 28

Which of the following assessment findings would the nurse identify as a normal response in a craniotomy client postoperatively?

Accepted Answer

Answer reason: A low-grade temperature for the first 2–3 days is an expected postoperative finding (often related to atelectasis or an inflammatory response). Decreased responsiveness on day 3 and sluggish pupils suggest neurologic deterioration. Frequent dressing changes are not routine and increase infection risk.

Question 29

Which symptom should be watched for after a total thyroidectomy?

Accepted Answer

Answer reason: After total thyroidectomy, injury to or removal of the parathyroid glands can cause acute hypocalcemia. A positive Chvostek sign indicates neuromuscular irritability from hypocalcemia and is the key complication to monitor. The other options reflect chronic hypothyroid effects, not the immediate postoperative risk.

Question 30

A female client who received general anesthesia returns from surgery. Postoperatively, which nursing diagnosis takes the highest priority for this client?

Accepted Answer

Answer reason: Post-op after general anesthesia, the gag and cough reflexes are depressed, creating an immediate airway threat. By the ABCs, preventing aspiration is the highest priority over pain, fluid deficit, or mobility.

Question 31

Potential post-intracranial-surgery problems include all but?

Accepted Answer

Answer reason: Post-craniotomy risks include increased ICP, seizures, and CSF leak; hemorrhage of concern is intracranial (epidural/subdural/intracerebral), not extracranial.

Question 32

A 67-year-old client with non-insulin-dependent diabetes should be instructed to contact the outpatient clinic immediately if the following symptoms are present?

Accepted Answer

Answer reason: Diabetic clients are at high risk for serious foot infections and rapid progression to ulceration and gangrene. An open heel wound warrants immediate evaluation. The other options are less urgent in this context.

Question 33

The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder?

Accepted Answer

Answer reason: Pheochromocytoma causes excess catecholamines, predisposing to hypertensive crises and dysrhythmias. An irregular heart rate indicates a potential dysrhythmia, whereas the other findings are within normal limits.

Question 34

The nurse is caring for a client after a hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action?

Accepted Answer

Answer reason: After transsphenoidal hypophysectomy, clear nasal drainage may be cerebrospinal fluid. The priority initial action is to test for glucose (or halo sign) to verify CSF leakage and notify the provider. Lowering HOB is contraindicated, culture is not the first step, and observation alone delays intervention.

Question 35

Three hours ago, a client was thrown from a car into a ditch, and he is now admitted to the emergency department in a stable condition with vital signs within normal limits, alert and oriented, with good color and an open fracture of the right tibia. For which signs and symptoms should the nurse be especially alert?

Accepted Answer

Answer reason: An open long-bone fracture can result in significant blood loss leading to hypovolemic shock. Although infection is a later risk and deformity is expected, immediate vigilance should focus on signs of shock (tachycardia, hypotension, pallor, restlessness).

Question 36

A nurse is caring for an infant with a tentative diagnosis of hypertrophic pyloric stenosis (HPS). What is most important for the nurse to evaluate?

Accepted Answer

Answer reason: Infants with hypertrophic pyloric stenosis have persistent non-bilious vomiting, placing them at high risk for dehydration and electrolyte imbalance; monitoring for dehydration is the priority assessment.

Question 37

You have obtained the following assessment information about a 3-year-old who has just returned to the pediatric unit after a tonsillectomy. Which finding requires the most immediate follow-up?

Accepted Answer

Answer reason: After tonsillectomy, frequent swallowing suggests active or occult oropharyngeal bleeding, a priority complication requiring immediate assessment and intervention. Sore throat is expected; hypoactive bowel sounds may occur after anesthesia; a HR of 112 is within normal range for a 3-year-old.

Question 38

After a tonsillectomy, a child begins vomiting bright red blood. Which initial action should the nurse take?

Accepted Answer

Answer reason: Bright red emesis after tonsillectomy indicates active bleeding. The priority is airway protection—position the child on the side to allow drainage and prevent aspiration. Then notify the HCP and keep NPO; antiemetic is not first.

Question 39

Immediate postoperative care following tracheoesophageal repair surgery is_____?

Accepted Answer

Answer reason: Airway maintenance is the immediate priority after tracheoesophageal repair due to risk of obstruction and aspiration. Analgesia and fluids are secondary; deep oral suctioning may jeopardize the anastomosis.

Question 40

A client has a laryngectomy and radical neck dissection for cancer of the larynx. Two tubes from the area of the incision are connected to portable wound drainage systems. Inspection of the neck reveals moderate edema even though the drainage systems are functioning. For which clinical indicator should the nurse assess the client?

Accepted Answer

Answer reason: Post-laryngectomy neck edema can obstruct the airway; an early sign of hypoxia/airway compromise is restlessness. Crackles suggest fluid overload, loss of gag reflex is not expected here, and cloudy drainage indicates infection rather than acute airway compromise.

Question 41

Which of the following nursing interventions is appropriate while caring for a child after a tonsillectomy and adenoidectomy?

Accepted Answer

Answer reason: Frequent swallowing can indicate postoperative bleeding after tonsillectomy/adenoidectomy. Using straws can dislodge clots, ice cream (dairy) increases mucus, and supine positioning increases aspiration risk.

Question 42

Which of the following assessments in a child with hemophilia would lead the nurse to suspect early hemarthrosis?

Accepted Answer

Answer reason: Early hemarthrosis in hemophilia presents with joint discomfort and guarding—children often refuse to move the affected joint. The other options suggest shock, superficial bruising, or fracture, not early joint bleeding.

Question 43

In a child with Hirschsprung's disease, the nurse noticed fever and explosive diarrhea. What is the immediate nursing intervention?

Accepted Answer

Answer reason: Fever and explosive diarrhea in a child with Hirschsprung’s disease indicate enterocolitis, a life-threatening complication. Immediate physician notification is critical for prompt management to prevent perforation and sepsis.

Question 44

A nurse is working in a busy emergency department on a hot summer day when four near-drowning victims are admitted. Which near-drowning victim should the nurse assess for signs of hypovolemia?

Accepted Answer

Answer reason: Saltwater aspiration is hypertonic and draws fluid from the intravascular space into the alveoli, causing pulmonary edema and intravascular volume depletion (hypovolemia). Freshwater sources (lake, bathtub, pool) more often cause hemodilution/hypervolemia.

Question 45

A patient discharged with a diagnosis of glomerulonephritis should be instructed to call the doctor if they gain how much weight?

Accepted Answer

Answer reason: Sudden weight gain signals fluid retention from renal dysfunction. Patients are taught to report a gain of about 2 lb (1 kg) in 24 hours.

Question 46

Which intervention should the nurse implement to help prevent atelectasis in a client with fractured ribs as a result of chest trauma?

Accepted Answer

Answer reason: Deep breathing and coughing expand alveoli and mobilize secretions, preventing atelectasis. Thoracic binders restrict chest expansion; pain medication should not be deferred as adequate analgesia facilitates deep breathing; prone on a soft mattress impairs ventilation.

Question 47

Which of the following would lead the nurse to suspect that a client with a fracture of the right femur may be developing a fat embolus?

Accepted Answer

Answer reason: Fat embolism after long-bone fractures presents primarily with sudden respiratory compromise (hypoxemia/ARDS). The other options are not characteristic findings of fat embolism.

Question 48

A nurse is caring for a 9-year-old child who underwent tonsillectomy. Which of the following observation by the nurse is most concerned?

Accepted Answer

Answer reason: Post-tonsillectomy the priority risk is hemorrhage. Bright red secretions indicate active bleeding and require immediate intervention. Dark brown secretions suggest old blood; HR 90 is acceptable for a child; infrequent (not frequent) swallowing is not worrisome.

Question 49

The nurse should carefully spot the infant with a tentative diagnosis of pyloric stenosis for?

Accepted Answer

Answer reason: Pyloric stenosis causes frequent projectile vomiting, leading to fluid loss and electrolyte imbalance; monitoring for dehydration is the priority.

Question 50

Which finding would alert a nurse that a hospitalized 6-year-old child is at risk for a severe asthma exacerbation?

Accepted Answer

Answer reason: Chronic systemic steroid dependence indicates severe persistent asthma and is a strong predictor of severe exacerbations. The other findings (no retractions, mild work of breathing, SpO2 95%) suggest mild current severity and do not indicate high risk.

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