Question 1

A client with a history of DVT is scheduled for long travel. What should the nurse include in teaching?

Accepted Answer

Answer reason: Long periods of immobility increase venous stasis and raise the risk of venous thromboembolism recurrence, so promoting calf-muscle pumping and venous return is key. Graduated compression stockings plus frequent ankle/foot exercises and periodic walking reduce stasis during travel. Caffeine-containing beverages can contribute to relative dehydration, which may increase blood viscosity, and immobility is contraindicated. Starting aspirin immediately before travel is not standard DVT prophylaxis and should not be advised without a provider’s plan (anticoagulant strategies are individualized).
Category reason: This item tests nursing teaching to prevent a complication (recurrent DVT/embolism) during prolonged travel, which is a patient-safety risk reduction intervention rather than basic anatomy/physiology knowledge.

Question 2

After renal biopsy, the nurse should position the client?

Accepted Answer

Answer reason: This reduces bleeding by applying direct pressure to the renal puncture site (posterior flank), which is the main immediate complication risk after a renal biopsy. Maintaining this position supports hemostasis and minimizes the chance of hematoma formation and hematuria. High Fowler’s and supine positioning do not provide the same localized pressure to the biopsy site. Close monitoring of vital signs and urine for blood is also essential because hemorrhage can be occult initially.
Category reason: This question tests a nursing intervention aimed at preventing post-procedure complications (bleeding) after a diagnostic biopsy, which fits Reduction of Risk Potential—Potential for Complications.

Question 3

A nurse is teaching about pacemaker care. Which statement by the client indicates a need for further teaching?

Accepted Answer

Answer reason: After pacemaker insertion, clients are typically instructed to limit ipsilateral arm movement above shoulder level for longer than one week (often about 2–4 weeks) to reduce the risk of lead displacement. The other statements reflect appropriate teaching: keeping a cell phone on the opposite side, passing through airport metal detectors (without lingering and informing security), and checking the pulse daily to monitor function. Therefore, limiting arm movement for only one week suggests incomplete understanding and need for further teaching.
Category reason: This question tests post-procedure nursing teaching to prevent device-related complications after pacemaker insertion, which aligns with monitoring and preventing potential complications.

Question 4

Which postpartum assessment finding requires immediate intervention?

Accepted Answer

Answer reason: B) Fundus deviated to the right A postpartum uterus should be firm and midline; deviation (commonly to the right) strongly suggests a distended bladder. A full bladder prevents effective uterine contraction and increases the risk of uterine atony and postpartum hemorrhage. This finding requires prompt nursing action (assess bladder, assist to void or catheterize per protocol) and reassessment of fundal position and lochia after emptying.
Category reason: This item tests recognition of an abnormal postpartum assessment finding that signals a complication risk (bladder distention leading to uterine atony/hemorrhage), which fits nursing surveillance and prevention of complications.

Question 5

After coronary angiography via femoral route, the client reports back pain and has a drop in BP. What complication is suspected?

Accepted Answer

Answer reason: B. Retroperitoneal bleeding Back pain with hypotension after a femoral artery catheterization strongly suggests bleeding into the retroperitoneal space from femoral/iliac vessel injury. This hemorrhage can be concealed externally, so the puncture site may look normal while the client becomes hemodynamically unstable. Immediate assessment for shock and rapid escalation of care (vital signs, hemoglobin/hematocrit, fluid/blood support, and provider notification) are priorities.
Category reason: This question tests recognition of a post–cardiac catheterization complication and the associated clinical signs requiring prompt nursing assessment and response, which fits monitoring for potential complications.

Question 6

A newborn's mother is diabetic. What newborn finding should the nurse closely monitor?

Accepted Answer

Answer reason: Infants of diabetic mothers are at high risk for early neonatal hypoglycemia because maternal hyperglycemia stimulates fetal pancreatic beta-cell hyperplasia and elevated insulin levels. After birth, the maternal glucose supply stops abruptly while circulating insulin remains high, driving glucose into tissues and lowering serum glucose. This can occur within the first hours of life and may cause jitteriness, lethargy, poor feeding, apnea, or seizures, so frequent glucose monitoring and prompt feeding or IV dextrose are key.
Category reason: This question asks what complication to monitor for in a specific newborn risk group, which is a nursing surveillance and complication-prevention decision rather than foundational science knowledge.

Question 7

After a nephrectomy (kidney removal), the preferred position is?

Accepted Answer

Answer reason: This positioning supports ventilation and comfort while protecting the surgical site and promoting drainage. Keeping the operative side down helps splint the incision, reduce tension on the wound, and decrease pain, which can improve coughing and deep-breathing effectiveness. Prone positioning can impair breathing and increase discomfort, and high Fowler’s with knees flexed is not specifically beneficial for nephrectomy and may increase strain or discomfort. Flat supine can be less optimal for respiratory expansion immediately post-op.
Category reason: This question tests appropriate postoperative positioning to prevent complications and promote recovery after a surgical procedure, which is a nursing intervention aimed at reducing risk potential.

Question 8

A client is 7 months pregnant and has just been diagnosed as having a partial placenta previa. She stable and has minimal spotting and is being sent home. Which of these instructions to the client may indicate a need for further teaching?

Accepted Answer

Answer reason: With placenta previa, anything that could stimulate bleeding (including intercourse and vaginal penetration) is typically restricted for the remainder of the pregnancy unless the provider clearly lifts the restriction. Bleeding risk is ongoing because the placenta overlies or approaches the cervical os and can shear with cervical changes or trauma. Therefore, a time-limited restriction of only a few days indicates misunderstanding and requires further teaching about pelvic rest and when to seek urgent care for bleeding or contractions.
Category reason: This item tests discharge teaching to reduce risk of hemorrhage and other complications in placenta previa, which is a nursing intervention focused on preventing complications.

Question 9

A client with chronic heart failure reports a 2.5 kg (5.5 lb) weight gain in 2 days. What is the best nursing response?

Accepted Answer

Answer reason: C. “This indicates fluid retention; we’ll notify the provider.” In chronic heart failure, a rapid weight gain of about 2–3 lb in 1 day or 5 lb in 1 week strongly suggests acute fluid retention and worsening volume overload. This finding is a potential complication that requires prompt clinical follow-up to prevent pulmonary edema and decompensation (e.g., need for diuretic adjustment and further assessment). Minimizing or normalizing the symptom delays necessary intervention, and focusing on diet alone does not address the immediate safety concern.
Category reason: This item tests nursing judgment in recognizing a sign of worsening heart failure and initiating an appropriate escalation of care to prevent complications, which fits Potential for Complications.

Question 10

A nurse is caring for a client who had a permanent pacemaker placed 3 hours ago. Which finding is most concerning?

Accepted Answer

Answer reason: B. Client reports hiccups Hiccups soon after pacemaker insertion can indicate diaphragmatic/phrenic nerve stimulation from lead displacement or perforation, which is a potentially serious complication requiring prompt assessment and device evaluation. This finding suggests abnormal pacing capture outside the heart or irritation of adjacent structures. In contrast, mild bruising at the site and low incisional pain are expected post-procedure findings, and a heart rate of 68 bpm is within normal limits unless symptomatic.
Category reason: This question tests recognition of an early post-procedure complication and the need for prompt nursing assessment/escalation after pacemaker insertion, which fits reduction of risk and monitoring for complications.

Question 11

Scenario: A nurse accidentally administers 10 units of regular insulin instead of the prescribed 6 units. Q. What is the nurse's immediate priority?

Accepted Answer

Answer reason: The most immediate patient safety risk from an insulin overdose is acute hypoglycemia, which can progress rapidly to neuroglycopenia, seizures, or coma. Immediate focused assessment and ongoing monitoring allow early detection of falling glucose so prompt treatment (e.g., oral carbohydrate or IV dextrose/glucagon per protocol) can be initiated. Notifying the provider and completing documentation are important but follow stabilization and prevention of imminent harm.
Category reason: This item asks for the nurse’s immediate priority action after a medication error, emphasizing prevention and early detection of a life-threatening complication from insulin administration.

Question 12

Which finding in a 10-week pregnant woman needs immediate attention?

Accepted Answer

Answer reason: C. Vaginal bleeding At 10 weeks’ gestation, vaginal bleeding can indicate threatened miscarriage, ectopic pregnancy, or other early pregnancy complications and warrants prompt assessment. Early recognition and evaluation (vital signs, amount of bleeding, pain, ultrasound and/or hCG as ordered) help prevent deterioration and guide urgent management. In contrast, nausea/vomiting, breast tenderness, and fatigue are common normal first-trimester findings that usually do not require emergent action unless severe or associated with dehydration or instability.
Category reason: This item tests nursing judgment to recognize an early-pregnancy warning sign requiring urgent evaluation to reduce risk of complications.

Question 13

Scenario: Before administering a tube feed, the nurse checks residual and finds 250 mL. Q. What is the appropriate action?

Accepted Answer

Answer reason: A gastric residual of 250 mL is generally considered elevated and can indicate delayed gastric emptying, increasing aspiration risk. Holding the feeding and reassessing helps reduce the likelihood of regurgitation and aspiration while allowing time for gastric motility to improve. Returning the residual helps prevent fluid and electrolyte loss unless facility policy specifies otherwise. Immediate provider notification is not typically required as the first step unless the residual remains high, the patient has symptoms (e.g., vomiting, distention), or repeated checks show persistently poor tolerance.
Category reason: This item tests a nursing action to prevent a complication (aspiration) by interpreting an enteral feeding assessment finding and choosing the safest next step, which fits Potential for Complications under Reduction of Risk Potential.

Question 14

A client with a cast on the right leg reports severe pain and numbness in the foot. What should the nurse do first?

Accepted Answer

Answer reason: B. Assess for compartment syndrome Severe pain with numbness distal to a cast suggests neurovascular compromise and possible compartment syndrome, which is a limb-threatening emergency. The priority is immediate assessment of circulation, sensation, movement, and escalating promptly for cast bivalving/fasciotomy if indicated. Giving analgesics could mask worsening ischemic pain and delay treatment, while heat can increase swelling and elevation may further reduce arterial perfusion if compartment syndrome is present.
Category reason: This question tests the nurse’s priority action to detect and prevent a serious complication of casting (neurovascular compromise/compartment syndrome), which aligns with monitoring for potential complications.

Question 15

Position for a patient receiving tube feedings with risk for aspiration:

Accepted Answer

Answer reason: C. High Fowler's or HOB at 30–45° Elevating the head of the bed uses gravity to reduce gastroesophageal reflux and decreases the likelihood that formula or gastric contents will be aspirated into the airway. This position also supports better airway protection and ventilation during enteral feeding. Supine and prone positions increase aspiration risk, and right lateral positioning alone is not the standard primary aspiration-prevention measure during tube feeding.
Category reason: This question tests a nursing intervention (patient positioning) to prevent a complication (aspiration) during enteral feeding, which aligns with reducing risk potential and preventing complications.

Question 16

The nurse is caring for a patient with suspected retinal detachment. What position helps prevent further damage?

Accepted Answer

Answer reason: D. Bedrest with head elevated and eye immobilized Limiting eye movement reduces vitreoretinal traction that can worsen the detachment or enlarge a retinal tear. Bedrest with head elevation helps stabilize the eye and can reduce further separation by minimizing sudden position changes and strain. Immobilizing the affected eye (often with a patch/shield) decreases saccadic movements that can propagate the detachment while awaiting urgent ophthalmologic management.
Category reason: This question asks for the safest nursing positioning intervention to prevent complications from a suspected retinal detachment, which is a patient-care action aimed at reducing risk of worsening injury.

Question 17

Following lumbar spinal surgery, what position helps reduce complications?

Accepted Answer

Answer reason: After lumbar spine surgery, maintaining neutral spinal alignment helps prevent stress on the operative site and reduces risk of bleeding, nerve injury, and disruption of surgical repair. Keeping the head flat (as ordered) and using logrolling minimizes spinal rotation and flexion/extension during repositioning. Positions that flex the hips/knees significantly or elevate the head can increase lumbar strain and discomfort and may worsen postoperative complications depending on the procedure and surgeon’s restrictions.
Category reason: This question tests postoperative nursing positioning to prevent harm and reduce surgical complications, which is a patient-safety/intervention judgment under Reduction of Risk Potential.

Question 18

Scenario: A patient with a suspected upper GI bleed is ordered an NG tube. Q. What is the nurse's priority before insertion?

Accepted Answer

Answer reason: Inserting an NG tube can traumatize fragile varices and precipitate massive hemorrhage, so screening for this high-risk history is a key safety step before proceeding. If varices are suspected, the nurse should clarify the order and anticipate alternative approaches per provider protocol to reduce bleeding risk. The other choices do not address the most serious potential complication prior to insertion and may be unsafe or inappropriate in an actively bleeding patient.
Category reason: This question tests a nursing safety check to prevent a serious complication before performing a procedure (NG tube insertion), which fits Reduction of Risk Potential—Potential for Complications.

Question 19

A post-term newborn was delivered with meconium-stained amniotic fluid. What is the priority action?

Accepted Answer

Answer reason: Meconium-stained amniotic fluid increases the risk of meconium aspiration with resulting airway obstruction and respiratory compromise. The immediate priority is to establish and maintain a patent airway by clearing secretions to support effective ventilation. Vigorous stimulation can provoke gasping and draw meconium deeper into the airway, while antibiotics and breastfeeding do not address the immediate airway risk.
Category reason: This is a patient-care priority question focused on preventing an acute complication (airway obstruction/aspiration) in a newborn, which fits NCLEX nursing judgment under Potential for Complications.

Question 20

Which newborn is at highest risk for cold stress?

Accepted Answer

Answer reason: B) Preterm newborn at 32 weeks Preterm infants have less subcutaneous fat, more permeable skin, and a larger surface-area-to-weight ratio, all of which increase heat loss. They also have limited brown fat stores and immature thermoregulation, making nonshivering thermogenesis less effective. As a result, they are more likely to develop hypothermia and cold stress without aggressive warming measures.
Category reason: This item tests nursing recognition of which newborn is most likely to develop a complication (cold stress) based on risk factors, aligning with monitoring for and preventing complications.

Question 21

After a cesarean section under spinal anesthesia, what is the most appropriate position for the client post-op?

Accepted Answer

Answer reason: C. Supine with uterus tilted laterally After spinal anesthesia and cesarean birth, positioning should reduce aortocaval compression to support maternal venous return and cardiac output, thereby maintaining uteroplacental perfusion and minimizing hypotension and nausea. A lateral uterine tilt (left tilt) is the standard intervention to prevent supine hypotensive syndrome in the immediate postoperative/postpartum period. Raising the legs does not address vena cava compression and can worsen respiratory mechanics, while prone or knee-flexed side-lying positions are not routine or practical for monitoring and recovery immediately after surgery.
Category reason: This is a postoperative nursing care question focused on safe positioning to prevent hemodynamic complications following spinal anesthesia, aligning with monitoring and preventing potential complications.

Question 22

A client is 2 hours postpartum and experiencing heavy vaginal bleeding despite a firm fundus. What is the likely cause?

Accepted Answer

Answer reason: A firm fundus makes uterine atony less likely, yet heavy postpartum bleeding persists, which points to trauma of the lower genital tract. Cervical or vaginal lacerations can bleed briskly even when uterine tone is adequate. Retained placental tissue more often presents with a boggy/poorly contracted uterus and subinvolution, though bleeding can occur. Immediate assessment should include inspection of the cervix/vagina and prompt repair if identified.
Category reason: This is a postpartum complication question requiring recognition of a cause of hemorrhage based on assessment findings (firm fundus with heavy bleeding), which is nursing-focused clinical judgment about potential complications.

Question 23

Following a tonsillectomy, the child is semi-conscious and bleeding from the mouth. What is the priority position?

Accepted Answer

Answer reason: This positioning helps maintain airway patency and promotes drainage of blood and secretions out of the mouth, reducing aspiration risk in a semi-conscious child. After tonsillectomy, active oral bleeding can quickly obstruct the airway or be aspirated if the child is supine. Turning the head to the side also allows better observation of ongoing bleeding while supporting rapid intervention.
Category reason: This question tests a nursing intervention to prevent an acute post-operative complication (airway obstruction/aspiration) through proper positioning, which fits Potential for Complications.

Question 24

The nurse is caring for a patient in a cast. Which sign requires immediate attention?

Accepted Answer

Answer reason: Numbness distal to a cast is a neurovascular compromise warning sign and may indicate increased pressure from swelling, compartment syndrome, or impaired perfusion. This finding requires urgent assessment of circulation, sensation, movement, and cast tightness to prevent permanent nerve and tissue injury. By contrast, warm toes and brisk capillary refill are reassuring perfusion indicators, and some pain can be expected unless severe, escalating, or unrelieved by analgesics.
Category reason: This question tests nursing recognition of and response to a potential complication (neurovascular compromise/compartment syndrome) in a patient with a cast, which is patient-safety focused clinical judgment.

Question 25

After cardiac catheterization via femoral artery, the nurse should position the client?

Accepted Answer

Answer reason: Maintaining a flat, supine position with the affected leg straight helps prevent bleeding and hematoma formation at the femoral arterial puncture site by minimizing hip flexion and stress on the vessel. It also supports formation of a stable clot and reduces risk of retroperitoneal hemorrhage. Upright positioning or sitting increases pressure and movement at the access site, raising the risk of complications that require urgent intervention.
Category reason: This question tests a nursing intervention to prevent post-procedure vascular complications after femoral cardiac catheterization, which aligns with monitoring and preventing potential complications.

Question 26

Position for post-thyroidectomy client to prevent tension on the suture line and edema:

Accepted Answer

Answer reason: B. Semi-Fowler’s with neck supported This position decreases venous congestion in the neck, helping reduce postoperative edema and airway risk. Supporting the neck keeps the head midline and limits flexion/extension that could strain the incision and suture line. It also promotes easier breathing and allows rapid assessment for complications such as bleeding or respiratory distress compared with prone or extreme neck positions.
Category reason: This is a postoperative nursing positioning intervention aimed at preventing complications (edema, suture-line tension, airway compromise), which aligns with monitoring/preventing complications in Reduction of Risk Potential.

Question 27

A nurse is caring for a client who is post-op day 1 after abdominal surgery. The client reports pain in the calf. What should the nurse do first?

Accepted Answer

Answer reason: C. Assess for signs of deep vein thrombosis (DVT) Post-op day 1 calf pain is a classic warning sign for venous thromboembolism, a potentially life-threatening complication due to risk of pulmonary embolism. The priority is to assess for DVT findings (e.g., unilateral swelling, warmth, tenderness, erythema) and promptly escalate care; interventions like massage or heat could dislodge a clot. Analgesics may mask symptoms and delay recognition of a serious complication, so assessment and safety come first.
Category reason: This is a patient-care priority question focused on recognizing and responding to a post-operative complication risk (DVT/PE), which fits NCLEX nursing judgment under Reduction of Risk Potential.

Question 28

A client with primary hyperaldosteronism is scheduled for adrenalectomy. What is the preoperative nursing priority?

Accepted Answer

Answer reason: Excess aldosterone causes sodium and water retention leading to hypertension, and potassium wasting leading to hypokalemia. Before surgery, stabilizing blood pressure reduces perioperative cardiovascular risk, and correcting hypokalemia helps prevent dysrhythmias and muscle weakness during anesthesia and recovery. Findings like striae and moon face relate more to hypercortisolism (Cushing syndrome), and hematuria is not a typical pre-op priority for this condition. Routine perioperative steroid administration is not the main priority unless adrenal insufficiency risk is present.
Category reason: This item asks for a preoperative nursing priority to prevent perioperative complications (hypertension and electrolyte imbalance) in a client with hyperaldosteronism, which aligns with nursing risk reduction and complication prevention.

Question 29

A patient receiving amiodarone for arrhythmia complains of dry cough and shortness of breath. What is the nurse's best action?

Accepted Answer

Answer reason: C. Notify the provider immediately Amiodarone can cause serious pulmonary toxicity (interstitial pneumonitis/fibrosis), and new dry cough with dyspnea is a red-flag adverse effect requiring prompt evaluation and likely discontinuation. Continuing the medication or only coaching breathing risks progression to respiratory failure. An inhaler is not an appropriate first response because the priority is recognizing and escalating a potentially life-threatening drug complication. Immediate provider notification supports rapid assessment (e.g., imaging, PFTs, oxygenation) and management.
Category reason: This question tests nursing recognition of a high-risk medication adverse effect and the safest immediate clinical action to prevent complications, which aligns with monitoring for and responding to potential complications.

Question 30

A client recovering from a thyroidectomy becomes restless and reports a tingling sensation in the lips. What should the nurse do first?

Accepted Answer

Answer reason: Restlessness and perioral tingling after thyroidectomy are classic early signs of hypocalcemia from inadvertent removal or stunning of the parathyroid glands, which can rapidly progress to tetany and laryngospasm. The priority is to promptly assess for this complication by evaluating calcium so treatment (e.g., IV calcium) can be initiated without delay if confirmed. Calling the surgeon may be appropriate after assessment/initial stabilization, but it is not the first action. Sedation could mask worsening neuromuscular irritability and oxygen does not address the underlying complication unless there are airway compromise signs.
Category reason: This is a postoperative nursing judgment question focused on recognizing and responding to a potential complication (hypocalcemia) after thyroidectomy, which aligns with Reduction of Risk Potential—Potential for Complications.

Question 31

The nurse is caring for a client scheduled for removal of a pituitary tumor using the transsphenoidal approach. the nurse should be particularly alert to?

Accepted Answer

Answer reason: D. Oliguria Transsphenoidal pituitary surgery places the posterior pituitary at risk, which can disrupt antidiuretic hormone regulation and cause major postoperative fluid-balance complications. A key early warning sign of hypopituitarism-related ADH deficiency or evolving hemodynamic instability is a change in urine output that requires prompt assessment and trending. Monitoring for reduced urine output is critical because it can signal inadequate perfusion or evolving endocrine-related instability requiring rapid intervention and lab evaluation. Nasal symptoms can occur with the approach, but they are expected local effects and are less likely to represent a high-risk systemic complication compared with urine output changes.

Question 32

The nurse is making initial rounds on a client with a C5 fracture and crutchfield tongs. Which equipment should be kept at the bedside?

Accepted Answer

Answer reason: Clients in skeletal traction with Crutchfield tongs are at risk for airway compromise or cardiopulmonary arrest, and the traction setup can impede rapid access to CPR or emergent procedures. Having wire cutters at the bedside allows the nurse to immediately cut traction cords and remove the weight system if ordered in an emergency to facilitate resuscitation and safe repositioning. This focuses on preventing life-threatening delays when the patient must be moved quickly or placed flat. Tools like a torque wrench or screwdriver are used for adjustment/maintenance and do not address urgent emergency release needs.

Question 33

Which of the following diagnoses is most appropriate for a patient with hypo calcemia?

Accepted Answer

Answer reason: Hypocalcemia increases neuromuscular excitability, which places the patient at risk for paresthesias, muscle cramps, tetany, and seizures; the key nursing priority is preventing injury from these complications. A nursing diagnosis framed as risk for injury best matches the safety-focused implications of low calcium. Among the listed options, the risk diagnosis most aligned with acute safety concerns is the injury-risk choice. Constipation is more typical of hypercalcemia, and ineffective airway clearance is not a primary expected consequence of isolated hypocalcemia. The inclusion of bleeding is less classic for hypocalcemia, but the injury-risk framing is still the best fit compared with the other distractors.

Question 34

The nurse is caring for four patients. Which patient does the nurse identify as at highest risk for acute pyelonephritis?

Accepted Answer

Answer reason: Acute pyelonephritis commonly results from ascending infection, and vesicoureteral reflux increases the likelihood that infected urine will flow back toward the kidneys. This promotes bacterial ascent and renal parenchymal involvement, raising risk beyond uncomplicated lower UTI. Although urinary tract stones can also predispose to infection, the strongest classic risk for recurrent kidney infection is reflux because it directly facilitates upward spread. Nursing risk identification prioritizes conditions that most directly enable renal involvement and rapid progression to systemic illness.

Question 35

A nurse is caring for a client who is post-bronchoscopy. Which of the following findings is of concern?

Accepted Answer

Answer reason: Coughing up blood suggests mucosal injury or hemorrhage and warrants prompt assessment of amount, vital signs, oxygenation, and notification of the provider. Mild sore throat and transient hoarseness are common expected effects from scope passage and local irritation. A headache is nonspecific and is less directly linked to a serious post-procedure complication than evidence of bleeding.

Question 36

A nurse is caring for a 2-month-old infant who is postoperative after receiving a ventriculoperitoneal shunt. Which of the following findings should the nurse report to the provider?

Accepted Answer

Answer reason: New abdominal distention can indicate peritoneal irritation, ileus, obstruction, or shunt-related malfunction/infection and warrants prompt evaluation. The other findings listed are expected for a 2-month-old (Moro reflex is normal at this age; RR 30/min is within the normal infant range; 37.3°C is not a fever). Because abdominal distention may signal a complication requiring intervention, it should be reported.

Question 37

Position of spina bifida

Accepted Answer

Answer reason: Prone positioning keeps pressure off the spinal defect and allows the lesion to remain free of contamination from urine or stool. Supine positioning would place direct pressure on the sac and increases risk of CSF leak and tissue breakdown. Prone can be paired with careful padding and frequent skin checks to minimize complications while awaiting surgical closure.

Question 38

A nurse is assisting with the care of an adolescent client who is in skeletal traction for the treatment of a fractured femur. Which of the following actions should the nurse take?

Accepted Answer

Answer reason: Skeletal traction with pins creates a direct portal for infection and local tissue injury, so preventing skin breakdown and contamination at/around pin sites is a priority complication-prevention action. Padding at the pin ends helps protect the client from accidental trauma and reduces pressure/friction that can lead to skin irritation, bleeding, and infection risk. A common distractor is altering dietary fiber; immobility increases constipation risk, so fiber and fluids are generally encouraged rather than reduced. Range-of-motion is typically performed to unaffected joints while maintaining traction alignment, and traction weights should hang freely (not be lifted or rested) to maintain consistent therapeutic pull.

Question 39

If a difference between apical pulse and radial pulse then what should nurse do ??

Accepted Answer

Answer reason: This finding indicates a potentially unstable cardiac rhythm and risk of decreased cardiac output, so escalation is required for prompt evaluation and orders (e.g., ECG, labs, medication adjustment). Oxygen or positioning may be supportive if hypoxia or respiratory distress is present, but they do not address the underlying dysrhythmia signaled by the pulse deficit. Reporting allows timely diagnosis and treatment to prevent complications like hypotension, syncope, or thromboembolism.

Question 40

A client is scheduled for surgery in 10 days for removal of a pilonidal cyst. The nurse notes that the client is diagnosed with adrenal insufficient and has been taking prednisone 5 mg PO bid. The nurse expects the physician to take which of the following actions? [1] Continue the medication as prescribed before surgery. [2] Discontinue the medication before surgery. [3] Reduce the dosage of medication before surgery. [4] Increase the dosage of medication before surgery.?

Accepted Answer

Answer reason: Surgical stress increases the body’s need for cortisol, and clients with adrenal insufficiency or chronic glucocorticoid therapy may be unable to mount an adequate endogenous response. Without perioperative “stress-dose” steroids, the client is at risk for adrenal crisis with severe hypotension, hypoglycemia, hyponatremia, and shock. Therefore the safe, expected management is to increase glucocorticoid coverage around surgery rather than stop or taper it. Holding or reducing the steroid preoperatively is a common cause of perioperative hemodynamic collapse in steroid-dependent patients.

Question 41

The nurse is caring for a post-operative patient has an indwelling urinary catheter. The nurse should contact the healthcare provider for which 24-hour urine output volume?

Accepted Answer

Answer reason: Expected adult urine output is typically at least about 0.5 mL/kg/hr (roughly ≥30 mL/hr), which approximates ≥720 mL in 24 hours for many adults. A 24-hour total of 600 mL is below this threshold and suggests oliguria, warranting provider notification to evaluate fluid status, obstruction/kinking, and renal function. The higher volumes listed are generally within or above minimum expectations and are less concerning for inadequate perfusion in isolation.

Question 42

The nurse is discussing the risk of wound disruption following surgery with another healthcare team member. It would be correct for the nurse to identify which condition is a potential cause of this complication?

Accepted Answer

Answer reason: Excess glucocorticoids, as seen in this condition, cause protein catabolism, thin/fragile skin, and suppressed immune response, all of which weaken incision integrity and raise infection risk that can precipitate dehiscence. In contrast, a bleeding disorder primarily increases postoperative hematoma/bleeding risk rather than directly impairing tensile strength of healing tissue. Therefore this endocrine condition is a classic systemic risk factor for postoperative wound disruption.

Question 43

An adaptation that indicates major complication after gastroscopy would be?

Accepted Answer

Answer reason: While mild nausea/vomiting can occur from sedation or gastric irritation, it is typically self-limited and not a hallmark of a major post-endoscopy complication. Difficulty swallowing raises concern for impaired airway protection and aspiration risk, making it a higher-acuity warning sign. Prompt assessment for neck/chest pain, subcutaneous emphysema, fever, or respiratory compromise is warranted and the provider should be notified immediately.

Question 44

A client with a chest tube for a pneumothorax has continuous bubbling in the water seal chamber. What should the nurse do?

Accepted Answer

Answer reason: The priority nursing action is to assess the system for disconnections/loose connections and briefly clamp sequentially (per policy) to localize whether the leak is from the client or the tubing/collection device. Clamping the tube immediately and leaving it clamped can create a tension pneumothorax and is unsafe unless momentary for troubleshooting. The provider can be notified after assessment if the leak appears to be from the client (e.g., persistent bubbling that stops when clamped near the patient) or cannot be corrected by tightening connections or replacing the drainage unit.

Question 45

A postpartum nurse notes that the uterus is boggy and displaced to the right. What should the nurse do first?

Accepted Answer

Answer reason: The immediate nursing priority is to remove the reversible cause by assisting the patient to empty the bladder (or catheterize per protocol if unable to void), which often allows the uterus to return to midline and firm up. Fundal massage is appropriate for uterine atony, but when lateral displacement is present, addressing bladder distention first targets the underlying problem and can reduce ongoing bleeding risk. Notifying the provider and documenting are important, but they occur after initiating the first-line corrective nursing action.

Question 46

A client undergoes transurethral resection of the prostate for benign prostatic hyperplasia. The client has a 3-way Foley catheter with continuous bladder irrigation. Which assessment is the best indication that the bladder irrigation flow rate is productive?

Accepted Answer

Answer reason: Light pink drainage indicates an adequate irrigation rate that is preventing clot formation without over-irrigating, and it reflects expected improving hematuria. Equal irrigation input and Foley output can be misleading because true urine output should make total output exceed the instilled amount; matching volumes may indicate poor urine production or inaccurate tracking. Stable vital signs and absence of spasms are supportive findings but do not directly demonstrate that irrigation is effectively clearing blood and preventing obstruction.

Question 47

The nurse is caring for a client with a venous stasis ulcer. Which nursing intervention would be most effective in promoting healing?

Accepted Answer

Answer reason: Compression therapy directly addresses the underlying pathophysiology by decreasing edema and enhancing venous blood flow, which improves tissue oxygenation and supports wound closure. Sterile dressing technique helps prevent infection but does not correct venous congestion, making it less effective as the primary healing intervention. Nutrition and debridement can be supportive in select cases, but without compression, the ulcer commonly persists or recurs.

Question 48

To evaluate a patient condition for cardiac catheterization, the nurse will palpate the pulse?

Accepted Answer

Answer reason: Palpating pulses distal to the insertion site directly evaluates for decreased perfusion from arterial spasm, thrombosis, occlusion, or a compressive hematoma. This is the most sensitive bedside check for an evolving complication that can threaten the extremity and requires prompt escalation. Checking only at or above the site can miss impaired downstream circulation despite a seemingly stable proximal pulse or insertion appearance.

Question 49

A client with a newly applied leg cast reports numbness and increasing pain not relieved by medication. What should the nurse do first?

Accepted Answer

Answer reason: The nurse’s first priority is to assess circulation, sensation, and movement distal to the cast (e.g., pulses, cap refill, skin color/temperature, motor function, paresthesia) to identify impairment that requires urgent provider notification and possible cast splitting/bivalving. Interventions like elevation or ice may be appropriate but can delay recognition of a rapidly evolving complication and are not the initial step when symptoms suggest ischemia. Repositioning addresses comfort but does not evaluate the potentially emergent cause of the symptoms.

Question 50

A newborn has a large myelomeningocele. What nursing intervention is priority?

Accepted Answer

Answer reason: A sterile, moist (nonadherent) dressing maintains hydration of the sac and provides a barrier to environmental contamination until surgical repair. Placing the newborn supine increases pressure and risk of rupture of the lesion, so positioning is not the safest first action. Assessments like anal tone or head circumference are important but are secondary to protecting the open defect and reducing the risk of meningitis and neurologic injury.

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