Question 1

The nurse assists a client who is in active labor. The client states, "The baby is coming now!" The nurse determines that a precipitous birth is imminent. Which action made by the nurse is the least important?

Accepted Answer

Answer reason: During an imminent precipitous birth, the priority is preventing neonatal and maternal injury by supporting controlled delivery of the head and immediately addressing life-threatening complications. Applying gentle pressure to the fetal head during crowning helps slow expulsion and reduces risk of perineal lacerations and fetal trauma. After the head delivers, checking for a nuchal cord is a time-critical step because an unrelieved tight cord can compromise fetal oxygenation. Actively applying downward traction is not a routine or necessary maneuver for the nurse in this setting and can increase risk of shoulder dystocia or brachial plexus injury, making it the least important action.

Question 2

The nurse is taking care of a client with a chest tube in place. She notices tidaling in the water seal chamber. What is the nurse's appropriate action?

Accepted Answer

Answer reason: An expected finding requires ongoing monitoring and documentation rather than urgent escalation. Immediate provider notification is more appropriate for signs of complication such as continuous bubbling (air leak), sudden cessation of tidaling with respiratory distress, or signs of tube obstruction. Assessing heart sounds is not the priority response to a normal chest drainage system finding; troubleshooting for air leak is prompted by persistent bubbling, not normal tidaling.

Question 3

The nurse is teaching a client who has Graves’ disease about self-management. Which of the following should the nurse include in the teaching plan?

Accepted Answer

Answer reason: C. Report any significant weight gain while taking the antithyroid medication. Antithyroid therapy for Graves’ disease can overshoot into hypothyroidism, so clients must monitor for clinical changes that signal under-treatment. Unexplained or significant weight gain suggests slowing metabolism and possible excessive medication effect, warranting prompt provider notification and thyroid function reassessment. This safety teaching helps prevent progression to symptomatic hypothyroidism and related complications. Thyroid replacement teaching is inappropriate in untreated Graves’ hyperthyroidism, and constipation prevention or fluid restriction are not primary, expected self-management priorities for this condition.

Question 4

What clinical indicator is important for the nurse to assess after a client undergoes a submucosal resection (SMR) for a deviated septum?

Accepted Answer

Answer reason: This finding can signal a disruption that allows air leakage and may progress, so early recognition prompts appropriate provider notification and monitoring. Mild blood-tinged drainage can occur postoperatively, but coughing up blood is less specific and not the key indicator of this complication. Voice changes are more relevant to laryngeal/pharyngeal procedures than septal surgery.

Question 5

When a patient is being treated for a renal calculus, the nurse anticipates?

Accepted Answer

Answer reason: Straining all urine is a key nursing intervention because it can capture the stone or fragments after hydration, medical expulsive therapy, or lithotripsy. Captured stones are sent for composition analysis (e.g., calcium oxalate, uric acid), which drives patient-specific dietary and medication recommendations. Measuring urine output is important for renal perfusion monitoring but does not directly verify expulsion, and specific gravity/24-hour collections are more relevant to metabolic evaluation rather than immediate treatment monitoring.

Question 6

The nurse is aware that which symptom is associated with an imperforate anus?

Accepted Answer

Answer reason: A key early clinical clue in the newborn is failure to pass meconium within the expected time frame because there is no functional anal opening or distal outlet. This finding should prompt inspection of the perineum and urgent evaluation for associated obstructive complications and other congenital anomalies. While vomiting can occur with intestinal obstruction, it is less specific than absent meconium passage for this particular defect.

Question 7

A nurse is caring for a client who is taking lithium carbonate to treat bipolar disorder. Which of the following diagnostic tests should the nurse recommend that the client undergo periodically?

Accepted Answer

Answer reason: Because this adverse effect may develop gradually and present with nonspecific symptoms (fatigue, weight gain, cold intolerance), periodic laboratory monitoring is required to detect dysfunction early. Routine monitoring also supports safe ongoing dosing and helps differentiate medication effects from mood symptoms. Chest X-ray, tonometry, and ERCP are not standard surveillance tests for lithium therapy-related complications.

Question 8

For which complication should a nurse be careful to monitor a patient after a liver biopsy?

Accepted Answer

Answer reason: Post-procedure nursing monitoring prioritizes early detection of internal bleeding through frequent vital signs, assessment for hypotension/tachycardia, increasing abdominal pain or distention, and signs of shock. This complication is both common enough and dangerous enough to be the primary surveillance focus compared with nonspecific symptoms like headache or muscle cramps. Respiratory distress is not the typical primary complication being monitored for immediately after a routine liver biopsy unless a separate complication is suspected.

Question 9

The nurse has provided discharge instructions to a client with an application of a halo device. The nurse determines that the client needs further teaching if which statement is made?

Accepted Answer

Answer reason: ” A halo vest restricts neck movement and can impair peripheral vision and overall ability to react quickly, creating a major safety risk with operating a vehicle. Teaching typically emphasizes avoiding driving (often until the provider clears it) because the device and any associated pain medications can further slow reaction time. Using caution with balance is appropriate because the frame shifts the center of gravity and increases fall risk. Skin care and hygiene measures under the vest liner are also important to prevent skin breakdown and infection.

Question 10

The nurse provides care to a pediatric client who is diagnosed with immune thrombocytopenic purpura (ITP). Which finding requires priority notification to the healthcare provider?

Accepted Answer

Answer reason: Visible blood in the urine suggests genitourinary bleeding and may indicate clinically significant hemorrhage requiring urgent evaluation, labs, and potential escalation of therapy. In contrast, petechiae and bruising are common cutaneous manifestations of low platelets and are usually expected findings unless rapidly worsening or extensive. Mucosal bleeding (e.g., gums) is concerning, but frank hematuria more strongly signals internal bleeding and warrants prompt provider notification.

Question 11

The nurse is caring for an adult client with idiopathic nephrotic syndrome. The nurse should prioritize monitoring the client’s?

Accepted Answer

Answer reason: The most immediate and clinically actionable complication to track is worsening fluid overload, which can progress from dependent swelling to ascites, pleural effusions, and pulmonary edema affecting oxygenation. Monitoring swelling trends (with associated daily weights and intake/output) helps detect deterioration early and guides diuretic and fluid/sodium management. Urine protein and lipids reflect disease activity but are less urgent for bedside safety than tracking evolving volume status that can compromise cardiopulmonary function.

Question 12

Before administering a scheduled 300 mL enteral feeding bolus to a comatose adult client, the nurse aspirates 100 mL of gastric residual volume. Which nursing action is MOST appropriate?

Accepted Answer

Answer reason: Withholding feedings unnecessarily increases risk of inadequate nutrition and delayed healing, especially in a comatose client who relies entirely on enteral intake. The safer approach is to proceed while continuing aspiration precautions (e.g., verify tube placement per policy and maintain head-of-bed elevation) and monitor for intolerance (vomiting, distention). Holding for two hours is more appropriate when residuals are markedly elevated or there are clinical signs of poor tolerance rather than this moderate volume alone.

Question 13

A community health nurse visits a patient who has suffered a stroke. The patient’s spouse explains to the nurse that the patient chokes on foods at times. Which of the following referral ordered would the nurse anticipate needing for this patient?

Accepted Answer

Answer reason: A speech-language pathologist is the primary discipline for bedside swallow evaluation, instrumental swallow studies as indicated, and teaching compensatory strategies and safe-consistency recommendations. This referral directly targets the complication risk (airway compromise/aspiration) rather than general dietary planning alone. Physical therapy focuses on mobility and function, and a neurologist manages medical stroke care but does not provide swallow rehabilitation.

Question 14

The immediate nursing intervention for a patient with epistaxis due to hemodialysis is?

Accepted Answer

Answer reason: Nasal packing provides direct pressure to the bleeding site to tamponade vessels when simple compression is not presented as an option. Dorsal recumbent positioning is inappropriate because it increases aspiration/swallowing of blood; the patient should generally be upright and leaning forward. Calling the doctor may be needed if bleeding persists, but it is not the first action when an effective bedside hemostatic intervention is available.

Question 15

A female patient suffers adult respiratory distress syndrome as a consequence of shock. The patient’s condition deteriorates rapidly, and endotracheal intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator, alarm sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?

Accepted Answer

Answer reason: A kinked ventilator circuit is a classic cause of sudden increased airway resistance and will trigger this alarm quickly. In contrast, a disconnected tube or cuff leak typically causes a low-pressure/low-exhaled-volume alarm because pressure cannot be maintained in the circuit. Changes in oxygen concentration relate to FiO2 monitoring and do not directly produce a high-pressure alarm unless a separate oxygen analyzer alarm is set.

Question 16

While changing the tapes on a tracheostomy tube, the male client coughs and tube is dislodged. The initial nursing action is to?

Accepted Answer

Answer reason: Retention sutures are placed specifically to help keep the tract identifiable and allow the stoma to be opened quickly if the tube comes out, reducing the risk of the opening collapsing and making reinsertion difficult. Activating those sutures immediately supports prompt recannulation/ventilation efforts by the team and prevents rapid deterioration from hypoxia. Calling a provider or respiratory therapy without first securing the stoma delays critical airway management. Covering the site risks occluding the only airway route in a patient dependent on the trach and does not address the immediate threat.

Question 17

A female adult client has a tracheostomy but doesn’t require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for?

Accepted Answer

Answer reason: Initial tracheostomy plugging trials are brief and closely monitored to assess airway patency and the client’s ability to breathe effectively through the upper airway without precipitating respiratory distress. A short initial interval allows early detection of increased work of breathing, hypoxemia, secretion burden, or inability to tolerate added resistance. Beginning with only seconds is typically too short to meaningfully evaluate sustained tolerance, while 30–60 minutes is more consistent with later-stage progression after the client has demonstrated stability with shorter trials. This approach reduces the risk of acute decompensation during the earliest step of decannulation readiness assessment.

Question 18

A nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client, knowing that the client is at risk for which acid-base disorder?

Accepted Answer

Answer reason: This shifts the serum toward alkalemia, often accompanied by hypochloremia and, via volume depletion/aldosterone effects, hypokalemia that helps maintain the alkalosis. The risk increases with ongoing suctioning, vomiting, or inadequate replacement of fluids/electrolytes. Respiratory disorders are not the primary expected effect because the problem originates from GI acid loss rather than altered ventilation.

Question 19

A nurse is assisting a physician with the removal of a chest tube. The nurse should instruct the client to?

Accepted Answer

Answer reason: This reduces the risk of pneumothorax and helps maintain lung expansion as the tube is withdrawn and the site is quickly occluded/dressed. The Valsalva maneuver (or holding the breath at end-expiration, per facility protocol) is a standard instruction for this step to minimize air entry. Options that involve uncontrolled breathing patterns do not reliably increase intrathoracic pressure and can increase the chance of air ingress during removal.

Question 20

You are turning your patient in bed and you see that this confused and lethargic patient had loose car keys and lipstick in the bed and had been lying on them. What is this person at risk for because of all three of these factors: the confusion, lethargy and items in the bed?

Accepted Answer

Answer reason: Hard objects in the bed create focal pressure points and shear, which can quickly impair capillary blood flow and cause tissue ischemia. This combination markedly raises risk for pressure injury and localized skin damage even if the patient is otherwise in bed. Falls are less directly linked to being supine on objects, whereas the immediate hazard here is pressure-related injury to skin and underlying tissue.

Question 21

A nurse is assessing a client who is post-op day #1 after a hemilaminectomy. The nurse removes the dressing as ordered and notes that the incision appears slightly red, with a small amount of serous drainage coming from the site. The edges of the incision are approximated. What is the next action of the nurse?

Accepted Answer

Answer reason: The safest nursing action is to follow the prescribed care (shower if ordered) while continuing focused assessment for progression such as increasing redness, warmth, purulent drainage, separation, fever, or escalating pain. Applying topical antibiotics without an order introduces unnecessary treatment and can mask evolving findings or contaminate the site. Calling for systemic antibiotics is not indicated without signs of infection or dehiscence and would be premature compared with ongoing monitoring.

Question 22

A client is discharged with a prescription for warfarin (Coumadin). What discharge instructions should the nurse emphasize to the client?

Accepted Answer

Answer reason: Going barefoot increases the chance of cuts or puncture wounds that could lead to prolonged bleeding and difficult-to-control hemorrhage. In contrast, increasing intake of vitamin K–rich foods (e.g., large amounts of spinach) can reduce anticoagulant effect and destabilize INR, so it is not advised. Education should emphasize safe footwear, fall/trauma prevention, and seeking care for bleeding that does not stop.

Question 23

A 77-year-old female client is diagnosed with depression with anxiety and is started on imipramine. Because of this client’s age, the nurse will take precautions for care related to which adverse effects?

Accepted Answer

Answer reason: Imipramine (a tricyclic antidepressant) commonly causes sedation and impaired alertness, especially early in therapy and with dose increases. Nursing precautions in a 77-year-old therefore focus on fall prevention, monitoring level of consciousness, and avoiding additional sedatives/alcohol. While dry mouth is common, it is less immediately safety-critical than sedation-related falls in this age group. Urinary frequency is not a typical anticholinergic concern; urinary retention would be more expected.

Question 24

A child with a right femur fracture is placed in skin traction until surgery can be performed. During assessment of the child, the nurse notes that the dorsalis pedis is absent on the right foot. Which action should the nurse take?

Accepted Answer

Answer reason: This finding requires immediate escalation so the traction setup, limb alignment, and need for urgent intervention can be evaluated and corrected. Pain medication or ice could mask progression while delaying definitive management. Simply releasing traction is not an independent nursing action in this context and should be done only with urgent provider direction while continuing rapid neurovascular assessment.

Question 25

A 4-year-old has just had a plaster cast applied to a fractured left arm. The nurse provides instructions to the parents regarding care for the cast. Which statement by the parent indicates a need for further instruction?

Accepted Answer

Answer reason: ” Applying lotions or powders near a cast can allow moisture and particles to seep under the cast, promoting skin maceration and creating an environment for infection and skin breakdown. Itching should be managed by keeping the skin clean and dry and using safe measures like cool air from a dryer or gentle tapping on the cast—never inserting objects or applying substances that can accumulate. Warmth as plaster dries is expected because the setting reaction generates heat. Touching up a soiled cast with a small amount of shoe polish and using a cool-setting blow dryer for mild wetness are commonly accepted cast-care instructions when done carefully to protect skin integrity.

Question 26

A child who has undergone spinal fusion for scoliosis complains of abdominal discomfort and has periods of vomiting. On further assessment, the nurse notes abdominal distention. The priority action by the nurse at this time would be to?

Accepted Answer

Answer reason: Post–spinal fusion abdominal distention with vomiting suggests a potential serious postoperative complication such as ileus, bowel obstruction, or (less commonly) superior mesenteric artery syndrome, which requires prompt medical evaluation. The priority is to escalate care because ongoing emesis and distention increase risk for aspiration, worsening obstruction, and fluid/electrolyte derangements. Symptomatic measures like an antiemetic or repositioning do not address the underlying cause and may delay definitive management (e.g., bowel rest, NG decompression, imaging, surgical consult). Increasing IV fluids may be supportive but is not the first priority over notifying the provider when signs point to an evolving complication.

Question 27

An adolescent is admitted to the hospital because of a suicide attempt with an overdose of acetaminophen (tylenol). Which blood values are most important for the nurse to monitor during the first 72 hours following ingestion of this overdose?

Accepted Answer

Answer reason: Acetaminophen overdose primarily causes hepatocellular injury due to toxic metabolite accumulation when glutathione is depleted, and this can evolve over the first 24–72 hours. Liver enzymes rise as hepatic necrosis develops, so trending transaminases (AST/ALT; sometimes listed as SGOT/SGPT) and LDH helps detect worsening liver damage and guides escalation of care. Renal indices may become abnormal later and are not the most sensitive early markers of the main life-threatening complication. Acid–base values can change with severe toxicity but are not as direct or routine for monitoring evolving hepatic injury in the first 72 hours.

Question 28

The client received lidocaine viscous before a gastroscopy was performed. Which of the following would be a priority for the nurse to assess during the postprocedure period?

Accepted Answer

Answer reason: Postprocedure nursing priority is to verify airway protection before allowing oral intake or fluids. Assessing this reflex helps prevent choking and aspiration pneumonia, which are immediate complications compared with other listed assessments. Urination, leg pain, and standing ability are not the primary risks created by oropharyngeal anesthesia in this context.

Question 29

A 46-yr old female client had a radical total mastectomy on her right breast. Her lymph nodes were removed at the same time. What measures to prevent long term injury in her right arm such as lymphedema or infection can the nurse teach her?

Accepted Answer

Answer reason: Elevating the arm promotes venous and lymphatic return via gravity, helping reduce interstitial fluid accumulation. This is a practical, high-yield preventive measure nurses teach post-mastectomy to reduce chronic swelling risk. A common distractor is tight clothing, which can further obstruct lymph flow and worsen edema rather than prevent it.

Question 30

A patient received spinal anesthesia. Which is most important for the nurse to monitor?

Accepted Answer

Answer reason: It can also lead to post–dural puncture headache from CSF leakage, typically worsening when upright and improving when supine, which nurses should assess and report. These complications directly relate to hemodynamic instability and neurologic symptoms that can impact patient safety soon after the block. In contrast, loss of consciousness is more characteristic of general anesthesia or excessive sedation rather than an expected effect of an appropriately administered spinal. Monitoring blood pressure trends, level of block, and headache features helps detect and manage complications early.

Question 31

A 31-yr old has returned to the post op surgical unit following a hysterectomy. The client’s care plan suggests the risk of hemorrhaging. How should the nurse best monitor the client’s post op bleeding loss?

Accepted Answer

Answer reason: Counting and inspecting pads provides the most direct, repeatable assessment of blood loss over time and allows escalation if saturation increases or clots appear. Swabbing once per shift is too infrequent and does not quantify ongoing loss. The other options do not measure bleeding and are not appropriate monitoring strategies for hemorrhage.

Question 32

The client for home skeletal traction asked the purpose for this type of traction. What is the nurse’s best response?

Accepted Answer

Answer reason: This stabilizes the injured extremity, helps prevent displacement, and supports appropriate healing while limiting harmful movement at the fracture site. While traction can also reduce muscle spasm as a secondary effect, the primary purpose the client should understand is maintaining bone alignment. Claims about preventing low back pain or preventing skin injury are not core goals of skeletal traction and could mislead the client about what traction is intended to accomplish.

Question 33

The client returning to the nursing unit after a total hip replacement has a wedge-shaped pillow strapped between his knees. The client’s family asked why this pillow is in place. What is the nurse’s best response?

Accepted Answer

Answer reason: After total hip arthroplasty, a primary early postoperative complication is prosthetic hip dislocation from violating hip precautions. The abduction wedge maintains proper alignment by keeping the legs abducted and preventing adduction/crossing the midline, which can lever the femoral head out of the acetabular component. This device is therefore used as a mechanical prevention strategy when the client is supine or turning, especially while still sedated or weak. Options focusing on ambulation timing or “inversely moving” the leg do not address the key safety goal of preventing dislocation through maintained abduction and midline protection.

Question 34

A 58-yr old female client had a right mastectomy with removal of lymph nodes. In which position would her nurse place her to minimize edema from the circular site?

Accepted Answer

Answer reason: Elevating the arm promotes venous and lymphatic return via gravity and helps reduce interstitial fluid accumulation at and distal to the surgical site. Semi-Fowler’s positioning also improves overall comfort and decreases upper-body venous congestion compared with flat positioning. Lying on the operative side can increase pressure on lymphatic/venous channels and worsen swelling, and Trendelenburg would increase upper-extremity and thoracic venous congestion rather than reduce it.

Question 35

Which action is most important for the nurse to implant to reduce the risk for deep vein thrombosis in a postoperative client?

Accepted Answer

Answer reason: Active leg and ankle exercises stimulate the calf muscle pump, improve circulation, and are a key nursing intervention especially when early ambulation is limited. Turning side-to-side primarily helps prevent pressure injury and supports pulmonary expansion, but it is less direct for preventing lower-extremity venous stasis. Changing an IV site is an infection/phlebitis prevention measure and does not address the primary mechanism of postoperative DVT.

Question 36

A nurse is caring for a 5-year-old with a fracture of the tibia involving the growth plate. When providing information to the parents, the nurse should indicate that?

Accepted Answer

Answer reason:  Growth plate (physeal) fractures in young children carry a significant risk of complications such as growth arrest, limb-length discrepancy, or angular deformity due to injury to developing cartilage. Parent teaching should therefore emphasize the need for close follow-up and monitoring for delayed sequelae even if pain improves and the bone appears to heal. Option B is unsafe reassurance because healing time varies and physeal injuries can have late complications. Option D may be true for symptom control but it does not address the key risk that parents must understand: potential long-term growth problems.

Question 37

The nurse is caring for a patient with abdominal hysterectomy. Which post op intervention by the nurse should be considered priority?

Accepted Answer

Answer reason:  Postoperative priorities follow ABCs, and once airway/breathing are stable the next priority is circulation and early detection of hemorrhage. After an abdominal hysterectomy, bleeding can occur internally and may first be suggested by increased drainage, saturation of dressings, or expanding wound drainage. Frequent dressing checks in the immediate postoperative period allow rapid recognition of hemorrhage and timely escalation of care before shock develops. Ambulation for flatus, leg exercises, and urine output monitoring are important, but they do not detect life-threatening bleeding as directly and urgently as close wound/dressing assessment.

Question 38

The nurse works in an eye surgery clinic, when teaching the patient about post op eye surgery complications, which symptom should be reported?

Accepted Answer

Answer reason: These complications can rapidly threaten vision and require urgent evaluation and treatment rather than routine reassurance. Mild itching is more consistent with expected postoperative irritation or dryness and is typically managed with prescribed drops and avoidance of rubbing. New flashes of light can indicate retinal traction/detachment and also warrants prompt reporting, but acute sharp pain is the most immediate warning sign of a potentially emergent postoperative problem.

Question 39

A client who had a wrist cast applied 3 days ago for a fractured wrist calls from home reporting that the cast is loose enough to fall off. How should the nurse respond?

Accepted Answer

Answer reason: This response provides appropriate client education and helps reduce unnecessary alarm while still encouraging monitoring for neurovascular compromise. Wrapping an elastic band around the cast is unsafe because it can create constriction and impair circulation. Reapplying a cast “because the wrist is swelling” contradicts the client’s report of looseness and reflects incorrect assessment of expected post-injury changes.

Question 40

A patient has a short arm plaster cast in the outpatient center for a wrist fracture. An understanding of discharge patient teaching is apparent when a patient states?

Accepted Answer

Answer reason: This statement reflects appropriate early cast care to manage inflammation around the fracture. Getting a plaster cast wet can weaken it and increase skin breakdown risk, even if dried. Instructing patients to avoid moving fingers/elbow is incorrect because gentle movement helps circulation and decreases stiffness; placing objects or lotions under the cast increases skin injury and infection risk.

Question 41

A female patient is scheduled to undergo a mastectomy of her right breast in the morning. What pre op information should the nurse provide the client?

Accepted Answer

Answer reason: Teaching the patient to expect a drain preoperatively decreases anxiety and supports safe postoperative self-care (e.g., measuring output, recognizing infection or blockage). Local anesthesia is not typical for a mastectomy, which is usually performed under general anesthesia. Withholding postoperative analgesia unless requested is inappropriate because proactive pain management and scheduled/PRN regimens are standard to promote breathing, mobility, and recovery.

Question 42

Which action by the nurse indicates understanding of herpes zoster?

Accepted Answer

Answer reason: Herpes zoster (shingles) causes vesicular lesions that contain infectious varicella-zoster virus, so preventing spread is a key nursing safety goal. Keeping lesions covered reduces direct contact with vesicle fluid and lowers transmission risk to susceptible individuals, especially pregnant or immunocompromised clients. Gloves are part of standard precautions but do not address airborne/contact considerations or the need to contain drainage from open lesions. Antibiotics do not treat viral zoster unless there is a secondary bacterial infection, and oxygen is not a routine intervention for this condition.

Question 43

The nurse is caring for a postoperative client who has voided 125 mL since the removal of the indwelling urinary catheter 6 hours ago. Which of the following actions should the nurse take?

Accepted Answer

Answer reason: A bedside bladder scan is a noninvasive assessment that distinguishes retention (high post-void residual) from inadequate urine production, guiding the safest next intervention. Waiting an additional hour can delay recognition of retention and increase risk of bladder overdistention and subsequent complications. Giving a diuretic or an IV bolus without first assessing bladder volume can worsen retention or cause unnecessary fluid/medication exposure.

Question 44

The nurse is caring for a client with a hyphema. The nurse should plan to take which action?

Accepted Answer

Answer reason: Hyphema is bleeding into the anterior chamber, and the key nursing priority is preventing rebleeding and minimizing further ocular injury that can increase intraocular pressure and threaten vision. An eye shield protects the globe from accidental trauma and reduces the chance of exacerbating bleeding. Supine positioning is inappropriate because care typically includes head elevation to help blood settle and reduce complications. Aspirin is contraindicated due to platelet inhibition and increased bleeding risk; cold compress is not the primary recommended intervention for established hyphema compared with protection, activity restriction, and monitoring for increased intraocular pressure.

Question 45

A nurse is caring for a patient who has just been notified via telephone of an elevated potassium level. After notifying the doctor, what is the highest priority action of the nurse?

Accepted Answer

Answer reason: Hyperkalemia can rapidly cause life-threatening conduction abnormalities and dysrhythmias, so immediate surveillance for electrical instability is the priority. Continuous ECG monitoring allows early detection of peaked T waves, PR prolongation, QRS widening, and progression toward ventricular arrhythmias or asystole so emergent treatment can be initiated promptly. Starting IV calcium may be indicated if there are ECG changes, but it requires a provider order and is not the safest universal first action before assessing rhythm status. Dietary restriction is slower acting, and giving potassium supplements would worsen the condition and is contraindicated.

Question 46

The nurse is caring for a newborn with a myelomeningocele who is awaiting surgical closure of the defect. Which assessment finding is of most concern?

Accepted Answer

Answer reason: Temperature of 101.8°F (38.8°C) Fever in a newborn with an open neural tube defect signals a high risk of infection (e.g., meningitis/sepsis), which can rapidly become life-threatening and requires urgent evaluation and treatment. Before surgical closure, the exposed sac/CSF pathways increase susceptibility to ascending infection, so temperature elevation is the most dangerous new finding. The other findings reflect expected neurologic/bowel dysfunction from the lesion and, while important, are typically chronic deficits rather than an acute systemic deterioration. A bulging sac with crying can occur with increased pressure/straining but is less immediately critical than evidence of systemic infection.

Question 47

A Patient was readmitted to the hospital with acute graft rejection. Which of the following assessment finding would be expected?

Accepted Answer

Answer reason: As glomerular filtration rate falls, nitrogenous waste products accumulate, leading to rising BUN and creatinine. Fever and hypertension are more typical than normal temperature or hypotension, reflecting an inflammatory and volume/RAAS response. A decreased WBC is not expected in rejection itself and would more strongly suggest bone marrow suppression or severe immunosuppression rather than an acute immune attack on the graft.

Question 48

The best position of a mother in first stage of labor is.........?

Accepted Answer

Answer reason: The left lateral position reduces vena cava compression, supports venous return and cardiac output, and can improve fetal oxygenation and fetal heart rate patterns. Supine positioning increases the risk of supine hypotensive syndrome and decreased placental blood flow. Lithotomy is primarily used for procedures/second stage and is not ideal for the first stage; knee-chest is typically reserved for specific situations like relieving cord compression rather than routine positioning.

Question 49

A child in postoperative ward under observation after tonsillectomy is suspected to have postoperative hemorrhage when the child?

Accepted Answer

Answer reason: Frequent swallowing (or repeated throat clearing) is an early and important sign of postoperative hemorrhage and should prompt immediate assessment of airway, vital signs, and inspection for bleeding. Pallor can occur with significant blood loss, but it is a later, less specific sign compared with the characteristic behavior of swallowing blood. Noisy snoring is more consistent with upper-airway obstruction from swelling/secretions, and thirst is common post-op and not specific for hemorrhage.

Question 50

A client requires a paracentesis. Which item is most important for the nurse to place at the client's bedside prior to the procedure?

Accepted Answer

Answer reason: Paracentesis can cause rapid intravascular fluid shifts and hypotension due to removal of large volumes of ascitic fluid, so immediate hemodynamic monitoring is the highest bedside priority. Having a cuff available supports frequent vital-sign checks and rapid recognition of shock or vasovagal responses during and after the procedure. Early detection allows prompt intervention (positioning, IV fluids/albumin as ordered, provider notification) to prevent deterioration. While measuring abdominal girth or weighing the client helps evaluate effectiveness, these are not as time-critical for detecting an acute complication.

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