Question 1

The nurse is caring for a 12-year-old girl with a history of spina bifida. The nurse is aware that this patient is at risk for developing which of the following conditions?

Accepted Answer

Answer reason: Many affected children also require intermittent catheterization, further increasing infection risk. Recurrent UTIs can be clinically subtle but can lead to reflux nephropathy and renal damage if unrecognized. The other options are not characteristic complications specifically linked to the neurogenic bladder/bowel dysfunction of spina bifida.

Question 2

At a community health fair, the blood pressure of a 62-year-old client is 160/96 mmHg. The client states “My blood pressure is usually much lower.” The nurse should tell the client to?

Accepted Answer

Answer reason: Advising repeat evaluation within 48–72 hours appropriately balances urgency with the need to recheck using proper technique and/or serial measurements. Immediate referral is typically reserved for markedly higher pressures (e.g., ≥180/120) or red-flag symptoms such as chest pain, neurologic deficits, or acute dyspnea. Waiting a week or two months delays confirmation and treatment initiation for a high-risk level in an older adult.

Question 3

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

Accepted Answer

Answer reason: Diabetes reduces protective sensation and impairs microvascular circulation, making even small foot breaks in skin high-risk for rapid infection, poor healing, and progression to ulceration/osteomyelitis. A heel wound also signals pressure-related tissue injury and requires prompt evaluation, offloading, and possible antibiotics or debridement to prevent limb-threatening complications. Low-grade temperature with dysuria suggests a possible UTI, but the scenario emphasizes the most urgent diabetes-specific complication that can deteriorate quickly without local care. Mild nausea/vomiting and insomnia/fatigue are nonspecific and typically warrant monitoring and supportive measures unless severe or persistent.

Question 4

A client has returned from a cardiac catheterization. Which one of the following assessments would indicate the client is experiencing a complication from the procedure?

Accepted Answer

Answer reason: An absent or diminished distal pulse indicates impaired perfusion and is an urgent complication that can progress to limb ischemia. Vital-sign changes like mild tachycardia or blood pressure elevation can be nonspecific and may relate to pain or anxiety rather than a direct access-site complication. Decreased urine output is less specific immediately post-procedure and would more commonly prompt evaluation for volume status or contrast-related issues, but it does not signal the classic immediate limb-threatening access complication.

Question 5

A client has developed thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority?

Accepted Answer

Answer reason:  The core priority in acute thrombophlebitis is preventing clot dislodgement and pulmonary embolism by minimizing venous trauma and limb motion. Keeping the client on strict bed rest limits ambulation and muscular pumping that could mobilize a thrombus while inflammation is active. Elevation and warm compresses can be supportive measures to reduce edema and discomfort, but they do not reduce the immediate embolic risk as directly as immobilization. Support stockings are typically avoided in the acute phase unless prescribed, because compression/manipulation can worsen pain and may increase risk of thrombus movement. The safest immediate nursing action is to restrict activity and monitor closely for signs of embolic complication.

Question 6

The nurse is caring for a 4 year-old 2 hours after tonsillectomy and adenoidectomy. Which of the following assessments must be reported immediately?

Accepted Answer

Answer reason: At 2 hours post-op, this change in behavior requires prompt evaluation of vital signs, throat/oral cavity, swallowing frequency, and respiratory status, and rapid notification of the provider. Throat pain is expected, and an apical rate of 110 can be within normal range for a 4-year-old depending on activity and discomfort. Dark emesis may occur from swallowed blood from surgery, but the priority “must report immediately” sign among these choices is the behavioral change suggesting possible active bleeding or deterioration.

Question 7

Which nursing action is a priority as the plan of care is developed for a 7 year-old child hospitalized for acute glomerulonephritis?

Accepted Answer

Answer reason: Trending blood pressure is a priority because rising pressures can signal worsening renal impairment and can precipitate serious outcomes such as hypertensive encephalopathy or pulmonary edema, requiring rapid intervention. Increased urinary output is not expected early because oliguria is common, so focusing on that misses the main immediate risk. Assessing edema is important, but blood pressure trends more directly reflect hemodynamic instability and guide timely escalation of care (e.g., fluid/sodium restriction, diuretics, antihypertensives as ordered).

Question 8

When planning the care for a young adult client diagnosed with anorexia nervosa which of these concerns should the nurse determine to be the priority for long term mobility?

Accepted Answer

Answer reason: In anorexia nervosa, amenorrhea reflects hypothalamic suppression with low estrogen, which accelerates osteopenia/osteoporosis and increases risk for stress fractures and vertebral compression that can limit function over time. Addressing the hormonal/nutritional drivers of bone loss is therefore a key long-term complication focus. Electrolyte imbalance is often more immediately life-threatening (arrhythmias) but is less directly tied to the chronic mobility endpoint being asked.

Question 9

A client has returned to the unit following a renal biopsy. Which of the following nursing interventions is appropriate?

Accepted Answer

Answer reason: Frequent assessment of blood pressure, pulse, and overall trends helps identify internal bleeding before overt signs become severe. Ambulation is typically delayed with bed rest to reduce bleeding risk, rather than encouraged at 4 hours. NPO for 24 hours is not routinely required post-biopsy, and dressing changes are done based on bleeding/soiling rather than a fixed 8-hour schedule.

Question 10

The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure?

Accepted Answer

Answer reason: Early ambulation and active or passive range-of-motion exercises activate the calf muscle pump, improving lower-extremity venous flow and reducing clot formation. In contrast, placing pillows under the knees can impair venous return by compressing popliteal vessels and increasing stasis. Leg massage is avoided because it can dislodge an unrecognized thrombus and precipitate embolization.

Question 11

A client has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care?

Accepted Answer

Answer reason: In early care planning, preventing and rapidly detecting major complications takes priority over longer-term problems like nutrition or coping. A hemorrhage can cause hypovolemic shock and airway compromise from hematemesis, so monitoring for GI bleeding and preparing emergency interventions is the most urgent focus. Fluid volume excess and malnutrition are important in cirrhosis/ascites, but they are typically less immediately fatal than acute variceal bleeding.

Question 12

The nurse is caring for a client with a pressure ulcer on the heel that is covered with black hard tissue. Which would be an appropriate goal in planning care for this client?

Accepted Answer

Answer reason: The key nursing goal is preventing breakdown and complications by offloading pressure, protecting the area, and monitoring for signs of infection or drainage that would suggest instability. Debridement is typically reserved for eschar that is unstable (wet, draining, erythematous, or lifting) or when infection is present. Protecting granulation tissue does not apply because eschar indicates necrotic tissue, and “heal infection” is not appropriate unless infection is identified.

Question 13

Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure?

Accepted Answer

Answer reason: A thrombus can form at or near the arterial access site and may embolize or cause acute limb ischemia, so monitoring distal pulses, extremity color/temperature, capillary refill, and new pain or numbness is critical in the first 24 hours. This complication is directly linked to arterial instrumentation and is a core safety surveillance priority immediately after the procedure. Symptoms like dizziness are nonspecific and can reflect many benign causes, and hypotension may occur but is more often a downstream sign of bleeding rather than a primary complication category to target over clot risk. Early recognition of thrombosis allows rapid intervention (e.g., anticoagulation or vascular evaluation) to prevent tissue loss or stroke.

Question 14

A nurse caring for premature newborns in an intensive care setting carefully monitors oxygen concentration. What is the most common complication of this therapy?

Accepted Answer

Answer reason: Excess oxygen suppresses VEGF and normal retinal vascular growth; subsequent relative hypoxia triggers abnormal neovascularization and scarring, risking retinal detachment and vision loss. This complication is classically associated with prolonged/high FiO2 exposure in preterm neonates, which is why continuous SpO2 monitoring and target saturation ranges are emphasized in NICU care. Bronchopulmonary dysplasia can also be related to oxygen and ventilation, but it is less specifically tied to oxygen concentration monitoring than the retinal toxicity risk. The other options are important prematurity complications but are not the characteristic complication of oxygen therapy itself.

Question 15

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

Accepted Answer

Answer reason: Early neuromuscular irritability (perioral tingling, paresthesias, carpopedal spasm/tetany) can rapidly progress to laryngospasm, seizures, and dysrhythmias, so it requires urgent provider notification and prompt calcium evaluation/replacement. By contrast, hoarseness may occur from transient laryngeal nerve irritation and is not automatically emergent unless accompanied by significant airway compromise. Headache/nausea or irritability/insomnia are nonspecific and do not signal a classic immediate, life-threatening post-thyroidectomy complication.

Question 16

A child is treated with edetate calcium disodium (Calcium EDTA) for lead poisoning. Which of these should the nurse assess first?

Accepted Answer

Answer reason: Nephrotoxicity is a key serious adverse effect, and decreased urine output is an early, actionable sign of impending kidney injury. Monitoring output also guides hydration needs to promote urinary elimination and reduce renal tubular exposure. Electrolytes (including calcium or potassium) can be monitored, but they are not as immediate or sensitive as urine output for detecting early renal compromise during chelation.

Question 17

The nurse is caring for a client who is in the late stage of multiple myeloma. Which of the following should be included in the plan of care?

Accepted Answer

Answer reason: Nursing care should therefore focus on preventing injury during routine movements by using gentle handling, logrolling as needed, and avoiding sudden twisting or excessive flexion. This directly reduces the risk of vertebral compression fractures and spinal cord compromise. Hyperkalemia is not a characteristic priority complication (hypercalcemia is more typical), and while diuretics may be used for hypercalcemia management, it is an order-dependent therapy rather than the core universal safety precaution. Protective isolation is not routinely indicated unless profound neutropenia is present and documented.

Question 18

A client has received her first dose of fluphenazine (Prolixin) 2 hours ago. She suddenly experiences torticollis and involuntary spastic muscle movement. In addition to administering the ordered anticholinergic drug, what other measure should the nurse implement?

Accepted Answer

Answer reason: g., torticollis, spastic muscle contractions) is an early extrapyramidal reaction to high-potency antipsychotics and can progress to laryngeal dystonia with airway compromise. After giving an anticholinergic, the priority is safety by preparing for potential respiratory obstruction and the need for emergent airway support. Seclusion does not treat the physiologic risk and may delay critical monitoring and intervention. Giving more antipsychotic would worsen dopamine blockade and can exacerbate extrapyramidal symptoms rather than relieve them.

Question 19

When caring for a client with advanced cirrhosis of the liver, which nursing diagnosis should take priority?

Accepted Answer

Answer reason:  Advanced cirrhosis causes impaired synthesis of clotting factors and thrombocytopenia, creating a high-risk, immediate threat of life-threatening bleeding. This risk is amplified by portal hypertension and varices, where hemorrhage can be sudden and massive, making prevention and early detection a top nursing priority. Ascites and malnutrition are serious but are generally less immediately lethal than an acute bleed and are addressed after stabilizing high-risk complications. Peripheral neuropathy increases fall risk, but it does not typically surpass the urgency of preventing catastrophic GI or variceal hemorrhage in advanced liver failure.

Question 20

The nurse detects blood-tinged fluid leaking from the nose and ears of a head trauma client. What is the appropriate nursing action?

Accepted Answer

Answer reason: A loose, bulky sterile dressing allows drainage to escape while minimizing contamination and permitting ongoing assessment of the amount/character of leakage. Packing the nares/ears or applying direct pressure can obstruct outflow, raise pressure, and potentially worsen the leak or complications. Cold application to the neck does not address the immediate complication risk associated with suspected CSF leakage.

Question 21

A PN is assigned to care for a newborn with a neural tube defect. Which dressing if applied by the PN would need no further intervention by the charge nurse?

Accepted Answer

Answer reason: A sterile, moist, nonadherent dressing maintains tissue hydration and provides a protective barrier without sticking to the lesion during removal. Ointments are generally avoided because they can be irritating/contaminating and are not needed for immediate protection, and pressure dressings can damage fragile neural tissue. An occlusive or pressure approach also increases risk by trapping heat/contaminants and applying harmful force, so the moist nonadherent sterile dressing is the safest initial nursing action.

Question 22

The nurse is planning care for a 3 month-old infant immediately postoperative following placement of a ventriculoperitoneal shunt for hydrocephalus. The nurse needs to?

Accepted Answer

Answer reason: Monitoring for increasing abdominal girth and distention helps identify impaired drainage or peritoneal irritation early. Keeping an infant strictly upright is not a routine immediate post-op requirement after VP shunt placement and positioning is typically guided by surgeon preference and neurologic status. Manipulating the device is inappropriate nursing practice because pumping can alter intracranial pressure and increases infection risk.

Question 23

The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which nursing intervention is appropriate for this child?

Accepted Answer

Answer reason: Traction is effective and safe only when body alignment is maintained so that the pulling force remains directed along the intended axis and does not create additional tissue or neurovascular injury. Ensuring midline positioning and proper alignment helps maintain fracture reduction and prevents complications such as pressure injury, nerve compression, and impaired circulation. Traction weights must hang freely and should not rest on the bed or floor, making the option that says weights touch the bed incorrect. Traction should not be released intermittently unless specifically prescribed because it can disrupt bone alignment and increase pain and risk of complications.

Question 24

A client with a fractured femur has been in Russell’s traction for 24 hours. Which nursing action is associated with this therapy?

Accepted Answer

Answer reason: Traction for a femur fracture can compromise distal perfusion and nerve function due to swelling, malalignment, or excessive/incorrect traction forces. The priority nursing action is frequent neurovascular assessment (color, temperature, capillary refill, pulses, sensation, and movement) to detect ischemia or compartment syndrome early. This directly evaluates the main limb-threatening complication of traction and guides urgent intervention if deterioration occurs. Pin-site infection assessment applies to skeletal traction with pins, not Russell’s traction, and sacral skin checks or lung auscultation are supportive but less specific and not as immediately limb-safety focused.

Question 25

The client with infective endocarditis must be assessed frequently by the home health nurse. Which finding suggests that antibiotic therapy is not effective, and must be reported by the nurse immediately to the healthcare provider?

Accepted Answer

Answer reason: Fever of 103 degrees Fahrenheit (39.5 degrees Celsius) Persistent or high fever during treatment for infective endocarditis is a red-flag sign of uncontrolled infection, possible antibiotic failure, or complications such as abscess formation or persistent bacteremia. This finding requires immediate provider notification because delays can lead to rapid clinical deterioration and embolic or cardiac complications. In contrast, nausea/vomiting and muscle tenderness are relatively nonspecific and may reflect medication side effects or general illness but do not by themselves indicate treatment failure. A diffuse macular rash can suggest a drug reaction that needs evaluation, but it does not most directly indicate lack of antibiotic effectiveness compared with ongoing high fever.

Question 26

A client had 20 mg of Lasix (furosemide) PO at 10 AM. Which would be essential for the nurse to include at the change of shift report?

Accepted Answer

Answer reason: Furosemide is a loop diuretic, so the most immediate safety/response indicator to communicate is the degree of diuresis and the associated risk for hypovolemia and electrolyte loss. This output reflects a strong diuretic response over a short interval and helps the oncoming nurse anticipate monitoring needs (vital signs, orthostasis, intake/output, and follow-up labs). A normal potassium level is important but is a single data point and may change with ongoing diuresis. Weight change is useful for trend assessment, but acute urine output better captures the current effect and potential complication risk at handoff.

Question 27

A 4 year-old has been hospitalized for 24 hours with skeletal traction for treatment of a fracture of the right femur. The nurse finds that the child is now crying and the right foot is pale with the absence of a pulse. What should the nurse do first?

Accepted Answer

Answer reason: This is an emergency complication requiring immediate provider evaluation and urgent interventions (eg, loosening/adjusting immobilization, restoring perfusion) beyond routine nursing measures. Waiting to reassess delays reperfusion and increases risk of ischemic injury. Giving PRN medication treats pain but does not address the underlying loss of circulation, and independently readjusting traction is not the safest first action when perfusion is already compromised.

Question 28

A client has been admitted to the Coronary Care Unit with a myocardial infarction. Which nursing diagnosis should have priority?

Accepted Answer

Answer reason: Myocardial ischemia and infarction make the myocardium electrically unstable, placing the patient at high risk for ventricular dysrhythmias that can quickly lead to decreased cardiac output or sudden cardiac arrest. This diagnosis drives immediate nursing actions such as continuous ECG monitoring, prompt recognition of rhythm changes, and readiness to intervene per protocol. Pain and anxiety are important and should be treated, but they are typically less immediately lethal than an evolving malignant dysrhythmia. Constipation is a non-urgent issue compared with preventing or detecting fatal complications early.

Question 29

A client is diagnosed with a spontaneous pneumothorax necessitating the insertion of a chest tube. What is the best explanation for the nurse to provide this client?

Accepted Answer

Answer reason: The key principle is that a pneumothorax is air in the pleural space that prevents full lung expansion. A chest tube connected to an appropriate drainage system evacuates pleural air and helps re-establish negative intrapleural pressure so the lung can re-expand. Draining fluid describes an effusion/hemothorax rather than a spontaneous pneumothorax. The tube does not directly seal a lung leak; it provides a route for air to exit while healing occurs and prevents ongoing accumulation.

Question 30

The nurse is caring for a 17 month-old with acetaminophen poisoning. Which of the following lab reports should the nurse review first?

Accepted Answer

Answer reason: Coagulation studies reflect hepatic production of clotting factors and often become abnormal early in clinically significant hepatotoxicity, guiding urgency of escalation and monitoring intensity. Transaminases indicate hepatocellular injury but do not directly measure functional failure or immediate bleeding risk in the same way. Renal indices are important but are typically a later/secondary concern compared with detecting evolving hepatic failure and coagulopathy in this setting.

Question 31

During an examination of a 2 year-old child with a tentative diagnosis of Wilms' tumor, the nurse would be most concerned about which statement by the mother?

Accepted Answer

Answer reason: Wilms’ tumor commonly presents as an enlarging, usually painless abdominal mass, and increasing abdominal girth suggests rapid tumor growth or associated abdominal distention. This finding raises concern for complications such as mass effect on nearby organs and potential tumor rupture/hemorrhage, which are important safety issues in suspected Wilms’ (avoid abdominal palpation/trauma). Weight loss can occur with malignancy but is less immediately specific to Wilms’ presentation than a growing abdominal mass. Decreased urine output is concerning but is not as classic an early hallmark as progressive abdominal enlargement and may reflect hydration or other non-oncologic factors without additional signs.

Question 32

The nurse is caring for a client with acute pancreatitis. After pain management, which intervention should be included in the plan of care?

Accepted Answer

Answer reason: Scheduled coughing and deep-breathing helps expand alveoli, mobilize secretions, and prevent postoperative-like pulmonary complications during periods of splinting. Contact isolation is not indicated unless a specific transmissible infection is present. A high-protein diet is not appropriate in the acute phase when clients are typically NPO or on careful nutritional support to reduce pancreatic stimulation, and seizure precautions are not routine for pancreatitis.

Question 33

The most effective nursing intervention to prevent atelectasis from developing in a post operative client is to?

Accepted Answer

Answer reason: Turning with deep-breathing and coughing directly promotes lung expansion, mobilizes secretions, and improves functional residual capacity, addressing the primary mechanism that leads to postoperative alveolar collapse. Early ambulation helps but is less immediately targeted than structured lung-expansion maneuvers and may be delayed by hemodynamic instability or surgical restrictions. Hydration and splinting support comfort and secretion clearance, but they do not provide the direct alveolar recruitment needed to most effectively prevent atelectasis.

Question 34

A client is admitted with infective endocarditis (IE). Which symptom would alert the nurse to a complication of this condition?

Accepted Answer

Answer reason: New or increasing shortness of breath reflects pulmonary congestion from impaired forward flow and is a key warning sign of this serious complication. A heart murmur is a common finding with valve involvement but is not, by itself, the clearest indicator that decompensation has occurred. Rash and bleeding can occur with systemic phenomena, but they are less specific for a life-threatening hemodynamic complication than respiratory compromise.

Question 35

A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing action?

Accepted Answer

Answer reason: Lung auscultation provides immediate, objective evidence of crackles and worsening respiratory status, allowing prompt intervention (slow/stop infusion, notify provider, oxygen/diuretics as ordered). Asking about breathing is subjective and may miss early findings, while vital signs are helpful but less sensitive than new adventitious breath sounds for early overload. Encouraging voiding does not address the potential acute respiratory complication and is not an appropriate priority response.

Question 36

The nurse is removing a fecal impaction on a 75 year-old client. It is most important that the nurse remember that?

Accepted Answer

Answer reason: This is the key safety concern during the procedure and drives close monitoring and stopping if the client becomes pale, diaphoretic, or reports dizziness. Timing relative to a bath is a comfort/organization issue, not a major physiologic risk. Increasing dietary fiber is preventive for constipation but does not address the immediate procedural complication risk.

Question 37

A nurse is caring for a client who had a closed reduction of a fractured right wrist followed by the application of a fiberglass cast 12 hours ago. Which finding requires the nurse's immediate attention?

Accepted Answer

Answer reason: A prickling/tingling sensation is an early warning sign that perfusion or nerve function is being impaired and warrants rapid assessment (pain, pulses, cap refill, movement, sensation) and prompt cast loosening/bivalving per protocol. Mild swelling and warm, normally colored skin are expected within the first 24 hours after reduction and casting. A capillary refill of 3 seconds may be borderline, but isolated without sensory changes is less immediately concerning than evolving neurologic symptoms.

Question 38

A man diagnosed with epididymitis 2 days ago calls the nurse at a health clinic to discuss the problem. What information is most important for the nurse to ask about at this time?

Accepted Answer

Answer reason: The priority in a follow-up call for acute scrotal inflammation is screening for time-sensitive complications that require urgent evaluation. New or worsening scrotal skin changes (increasing erythema, warmth, marked swelling, induration, or skin breakdown) can indicate progression to abscess, severe infection, or other acute scrotal emergencies rather than uncomplicated epididymitis. This assessment question helps determine severity and whether the client needs immediate in-person assessment or emergency referral. Pain control matters, but incomplete relief is less specific for dangerous deterioration than objective changes in the scrotal skin and local findings.

Question 39

The RN is planning care at a team meeting for a 2 month-old child in bilateral leg casts for congenital clubfoot. Which of these suggestions by the PN should be considered the priority nursing goal following cast application?

Accepted Answer

Answer reason: Prioritizing perfusion focuses nursing care on frequent circulation checks (color, warmth, capillary refill, pulses, movement, sensation) and rapid escalation for warning signs such as increasing pain unrelieved by analgesics, numbness, pallor, or diminished pulses. Pain control and spasm relief are important but are secondary because they do not address the immediate risk of ischemia and compartment syndrome. Mobility planning can occur after circulation is confirmed stable and the infant is not showing signs of impaired perfusion.

Question 40

The health care provider order reads "aspirate nasogastric feeding (NG) tube every 4 hours and check pH of aspirate." The pH of the aspirate is 10. Which action should the nurse take?

Accepted Answer

Answer reason: Gastric aspirate is typically acidic; a high pH can indicate placement in the small intestine or respiratory tract, or altered gastric acidity, and warrants verification before use. The safest nursing action is to stop the feeding and escalate for further evaluation/confirmation per policy (e.g., radiographic verification if needed). Continuing feeds despite questionable placement is a preventable complication, while cola irrigation and suction are inappropriate and do not address the immediate safety risk.

Question 41

An infant has just returned from surgery for placement of a gastrostomy tube as an initial treatment for tracheoesophageal fistula. The mother asks: "When can the tube can be used for feeding?" The nurse's best response would be which of these comments?

Accepted Answer

Answer reason: Newly placed gastrostomy tubes are typically connected to gravity drainage initially to decompress the stomach and prevent gastric distention, reflux, and aspiration while bowel function and tube patency are assessed. Decompression helps confirm the tube is functioning and reduces pressure on the fresh surgical site, lowering risk of vomiting and pulmonary complications. Starting feeds immediately can increase aspiration risk and may not allow time to evaluate output or tolerate gastric decompression first. Waiting for complete incision healing or 5–7 days is unnecessarily delayed in many postoperative protocols, as feeding is often resumed once ordered after initial decompression and clinical assessment.

Question 42

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: New or localized decreased breath sounds can indicate aspiration into the bronchial tree or developing atelectasis/pneumonitis, which is an airway/breathing threat requiring immediate assessment and action (stop feeding, check tube placement, suction, assess oxygenation, notify provider as indicated). A gastric residual of 100 mL alone is often monitored and trended rather than treated as an emergent finding unless accompanied by other intolerance signs. Decreased bowel sounds and 250 mL urine output over 8 hours warrant follow-up, but they do not typically represent the same immediate risk to oxygenation as a potential aspiration-related respiratory change.

Question 43

A 1 year-old child is receiving temporary total parenteral nutrition (TPN) through a central venous line. This is the first day of TPN therapy. Although all of the following nursing actions must be included in the plan of care of this child, which one would be a priority at this time?

Accepted Answer

Answer reason: On the first day, close glucose monitoring allows rapid adjustment of infusion rate or insulin therapy to prevent dehydration, electrolyte shifts, and neurologic compromise. Central line care and integrity are essential but are ongoing preventive measures rather than the most immediate metabolic threat at initiation. Liver function tests are more relevant to longer-term TPN complications (e.g., cholestasis) and are not the first-day priority compared with glucose instability.

Question 44

A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were T-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings taken now may be an early indication that the client is developing a complication of labor?

Accepted Answer

Answer reason: A rise from a baseline around 148 to 168 suggests a clinically meaningful change that warrants prompt reassessment and possible provider notification, especially in the setting of ROM and planned induction. A maternal temperature of 100°F is only a low-grade elevation and is less specific for infection than fetal tachycardia early on. Cervical dilation of 4 cm reflects labor progress, and a BP of 138/88 is not diagnostic of an acute labor complication in this context.

Question 45

A hospitalized child suddenly has a seizure while his family is visiting. The nurse notes whole body rigidity followed by general jerking movements. The child vomits immediately after the seizure. A priority nursing diagnosis for the child is?

Accepted Answer

Answer reason: Vomiting immediately postictally greatly increases the risk of aspiration and subsequent respiratory compromise, so this diagnosis drives urgent interventions such as lateral positioning, suction readiness, and oxygen as needed. Infection risk and family coping concerns are not immediate life threats in this moment. Fluid volume deficit may occur with ongoing vomiting, but it is a secondary concern compared with preventing aspiration and maintaining ventilation.

Question 46

To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must

Accepted Answer

Answer reason: Limiting each suction pass to a brief duration minimizes interruption of ventilation and reduces the risk of hypoxemia and dysrhythmias. Sterile technique is essential to prevent infection, but it does not directly prevent hypoxia during the act of suctioning. Proper withdrawal technique may improve secretion removal, yet the key hypoxia prevention measure is strict time limitation per pass with breaks for reoxygenation as needed.

Question 47

The nurse is caring for a 20 lbs (9 kg) 6 month-old with a 3 day history of diarrhea, occasional vomiting and fever. Peripheral intravenous therapy has been initiated, with 5% dextrose in 0.33% normal saline with 20 mEq of potassium per liter infusing at 35 ml/hr. Which finding should be reported to the health care provider immediately?

Accepted Answer

Answer reason: Lack of measurable output for 4 hours in a 6-month-old is an urgent change in perfusion/renal function that requires immediate provider notification and reassessment of fluid therapy and electrolytes. This finding can also indicate worsening hypovolemia despite infusion, needing rapid evaluation and possible bolus or different fluid composition. By comparison, irritability or vigorous sucking can be consistent with mild dehydration or normal infant behavior, and vomiting is concerning but is less immediately high-risk than absent urine output in the setting of potassium-containing IV fluids.

Question 48

The nurse is caring for a client who is post-op following a thoracotomy. The client has 2 chest tubes in place, connected to 1 chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the most appropriate nursing action?

Accepted Answer

Answer reason: The key safety principle is to differentiate normal, intermittent bubbling from continuous bubbling, which suggests an air leak in the system or ongoing pneumothorax. Ongoing assessment for a change to continuous bubbling, new respiratory distress, subcutaneous emphysema, or worsening oxygenation guides escalation. Clamping the tube is avoided unless briefly ordered for troubleshooting because it can rapidly cause a tension pneumothorax; asking the client to avoid coughing is inappropriate because coughing supports secretion clearance and lung expansion.

Question 49

The nurse is caring for a client on mechanical ventilation. When performing endotracheal suctioning, the nurse will avoid hypoxia by?

Accepted Answer

Answer reason: Pre- and post-oxygenation increases the client’s oxygen reserve and helps prevent desaturation during and immediately after the suction pass. The other choices promote unsafe technique: suction duration should be brief (generally ≤10–15 seconds) and excessive negative pressure increases mucosal trauma and hypoxemia risk rather than preventing it. Rotating or prolonged passes increase airway irritation and oxygen deprivation, so preventing hypoxia hinges on appropriate hyperoxygenation and limiting suction time.

Question 50

On daily cleaning of a tracheostomy, the client coughs and displaces the tracheostomy tube. The nurse could have avoided this by?

Accepted Answer

Answer reason: Applying the new ties first maintains continuous stabilization while the old ties are removed, minimizing tube movement. Having an assistant can help but does not replace the essential safety step of securing the tube before loosening its only fixation. Keeping an obturator at bedside is a preparedness measure for reinsertion after displacement, not a preventive step during tie changes.

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