Question 1

A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse?

Accepted Answer

Answer reason: The immediate nursing priority is to protect the eyes (e.g., lubrication, shielding, elevating HOB, reducing exposure) and promptly notify the provider for urgent evaluation and treatment. The other findings (weight loss, restlessness, irritability) are common hyperthyroid manifestations but are not typically as time-sensitive for preventing irreversible injury on initial assessment. Quick intervention focuses on preventing corneal abrasion/ulceration and vision loss.

Question 2

The nurse is caring for a client with active tuberculosis who has a history of noncompliance. Which of the following actions by the nurse would represent appropriate care for this client?

Accepted Answer

Answer reason: For a client with known noncompliance, directly observed therapy–style supervision is the most effective nursing approach to ensure each dose is taken as prescribed. Enlisting a reliable family member to monitor daily dosing supports adherence in the home setting and reduces the likelihood of ongoing infectiousness and complications. A common distractor is masking in public, which does not address missed doses and is not the key intervention for preventing resistance and ongoing transmission in a nonadherent client.

Question 3

Which information is a priority for the nurse to reinforce to an older client after intravenous pyelography?

Accepted Answer

Answer reason: IV pyelography uses iodinated contrast, and the priority after the test is early detection of contrast-related renal impairment, especially in older adults who are at higher risk for decreased renal reserve. Monitoring urine output provides a direct, timely indicator of kidney perfusion and function and identifies oliguria that can signal acute kidney injury requiring prompt evaluation. Encouraging fluids is helpful to promote contrast excretion, but it is a supportive measure and may be unsafe without individualized limits (e.g., heart failure) and does not replace monitoring for a complication. Diet and rest instructions are comfort-focused and are not priority safety teaching compared with surveillance for decreased urine output.

Question 4

Which client data should the nurse act upon when a home health aide calls the nurse from the client's home to report these items?

Accepted Answer

Answer reason: A sudden change to very dark urine in a catheterized client is a red-flag finding that can indicate dehydration, hematuria, bilirubinuria, or infection/complications and warrants prompt nursing assessment and follow-up. Indwelling catheters increase risk for CAUTI and urinary obstruction, so abnormal urine color can be an early sign of deterioration requiring timely intervention (vitals, intake/output, catheter patency, urine characteristics, and possible provider notification). In contrast, poor sleep for a week and “slower days” are nonspecific, lower-acuity concerns, and discontinuing a meal service is a planning/support issue rather than an immediate physiologic risk. Prioritizing potential complications aligns with preventing rapid decline and addressing reversible causes early.

Question 5

Which of these clients who call the community health clinic would the nurse ask to come in that day to be seen by the health care provider?

Accepted Answer

Answer reason: Painless gross hematuria is a red-flag finding because it can indicate significant pathology (e.g., urinary tract malignancy or other serious bleeding source) and warrants prompt same-day evaluation. The absence of dysuria makes uncomplicated cystitis less likely and shifts concern toward causes that may not produce pain. In contrast, menstrual contamination can explain red-tinged urine and is usually managed with education and follow-up unless other symptoms occur. Hourly urination in a diabetic can reflect hyperglycemia and needs timely assessment, but painless frank blood in urine is a higher-risk potential-complication presentation for urgent workup.

Question 6

A neonate born 12 hours ago to a methadone maintained woman is exhibiting a hyperactive MORO reflex and slight tremors. The newborn passed one loose, watery stool. Which of these is a nursing priority?

Accepted Answer

Answer reason: Hyperactive Moro reflex and tremors within the first day of life are classic early neurobehavioral signs that warrant structured assessment (e.g., scoring, frequent vitals, feeding/sleep evaluation). A single loose stool is less immediately threatening than the broader withdrawal picture and may be part of opioid withdrawal. Comfort measures and hydration can be implemented after the priority assessment clarifies severity and guides interventions/possible pharmacologic management. Paregoric (opium-containing) is not an appropriate first-line nursing response and is unsafe due to opioid content and risk of respiratory/CNS depression.

Question 7

The family of a 6 year-old with a fractured femur asks the nurse if the child's height will be affected by the injury. Which statement is true concerning long bone fractures in children?

Accepted Answer

Answer reason: Longitudinal bone growth occurs at the epiphyseal (growth) plate, so injury there can disrupt chondrocyte proliferation and lead to premature closure or asymmetric growth. This makes growth disturbance a recognized complication of pediatric long-bone fractures that involve the physis and is a key teaching point for families concerned about future height or limb length. Periosteal injury alone does not typically determine long-term growth because the periosteum primarily contributes to appositional (width) growth and remodeling. Rapid healing in children reduces nonunion risk but does not eliminate the specific risk of growth-plate arrest when the epiphysis is involved. Adequate blood supply supports healing but cannot fully prevent physeal damage–related growth delay if the growth plate has been disrupted.

Question 8

The nurse is at the community center speaking with retired people. To which comment by one of the retirees during a discussion about glaucoma would the nurse give a supportive comment to reinforce correct information?

Accepted Answer

Answer reason: Patients with glaucoma should avoid activities that increase intraocular pressure; straining/Valsalva during constipation can transiently raise IOP and worsen optic nerve damage risk. Maintaining soft stools with hydration and fiber is a practical prevention strategy that supports safer physiologic function. In contrast, the other statements either describe nonspecific visual symptoms or unnecessary activity restriction and do not reflect a key complication-prevention teaching point for glaucoma. Reinforcing bowel-regularity measures aligns with reducing risk of glaucoma-related worsening.

Question 9

The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must wait 6 weeks before having sexual intercourse. What is the best response by the nurse to this question?

Accepted Answer

Answer reason: " Resuming sexual activity after an MI should be guided by functional capacity and absence of exertional symptoms rather than an arbitrary time frame. Being able to climb two flights of stairs without chest pain, undue dyspnea, dizziness, or palpitations is a practical proxy for tolerating the cardiovascular workload of intercourse (about moderate exertion). This response gives the client a clear, measurable safety benchmark and encourages symptom monitoring to reduce the risk of ischemia or dysrhythmias. A common unsafe distractor is using alcohol to “relax,” which can worsen hypotension, interact with cardiac medications, and impair judgment about symptoms.

Question 10

A nurse aide is taking care of a 2 year-old child with Wilms' tumor. The nurse aide asks the nurse why there is a sign above the bed that says DO NOT PALPATE THE ABDOMEN? The best response by the nurse would be which of these statements?

Accepted Answer

Answer reason: " Wilms tumor is a renal malignancy that can be encapsulated, and vigorous palpation can rupture the tumor and seed malignant cells locally or into the bloodstream, worsening staging and prognosis. The bedside precaution to avoid abdominal palpation is specifically aimed at preventing tumor disruption and metastasis. Discomfort alone is not the primary safety issue, and infection spread is not the typical risk from palpation in this condition. The remaining statements are vague and do not identify the key complication the precaution is designed to prevent.

Question 11

A client with pneumococcal pneumonia had been started on antibiotics 16 hours ago. During the nurse’s initial evening rounds the nurse notices a foul smell in the room. The client makes all of these statements during their conversation. Which statement would alert the nurse to a complication?

Accepted Answer

Answer reason: Foul odor and foul-tasting, thick brown sputum suggest anaerobic infection with lung abscess or necrotizing pneumonia, which is a complication requiring prompt provider notification and possible change in therapy. Pneumococcal pneumonia classically produces rust-colored sputum, but a putrid smell points away from uncomplicated pneumococcal disease and toward tissue necrosis and abscess formation. Pleuritic chest pain can occur with pneumonia itself from pleural inflammation and is not as specific for a new complication. Sweating and intermittent fever can persist early in treatment and are less concerning than evidence of putrefactive sputum and malodor.

Question 12

A client who was medicated with meperidine hydrochloride (Demerol) 100 mg and hydroxyzine hydrochloride (Vistaril Intramuscular) 50 mg IM for pain related to a fractured lower right leg 1 hour ago reports that the pain is getting worse. The nurse should recognize that the client may be developing which complication?

Accepted Answer

Answer reason: This complication can develop within hours of injury and the pain is often out of proportion to the injury and may not be relieved by medication, signaling possible ischemia. The other choices are less consistent with the timing and symptom focus: fat embolism typically presents with respiratory distress and neurologic changes, and osteomyelitis is a later infectious complication. Recognizing this pattern is crucial because it requires urgent assessment and rapid intervention to prevent neurovascular compromise and limb loss.

Question 13

The nurse is caring for 2 children who have had surgical repair of congenital heart defects. For which defect is it a priority to assess for findings of heart conduction disturbance?

Accepted Answer

Answer reason: After closure of a septal defect, monitoring for dysrhythmias and varying degrees of AV block is therefore a priority because it can rapidly compromise cardiac output. A ventricular septal repair is anatomically closest to key conduction pathways compared with PDA ligation or many ASD repairs. Ongoing assessment includes heart rate/rhythm changes, new bradycardia, hypotension, and ECG evidence of AV conduction delay.

Question 14

The nurse is caring for a client 2 hours after a right lower lobectomy. During the evaluation of the water-seal chest drainage system, it is noted that the fluid level bubbles constantly in the water seal chamber. On inspection of the chest dressing and tubing, the nurse does not find any air leaks in the system. The next best action for the nurse is to?

Accepted Answer

Answer reason: Since the nurse has already assessed the dressing and tubing and cannot identify a correctable external leak, the leak may be coming from the client (e.g., bronchopleural fistula) or a malfunction that requires provider evaluation. Prompt escalation is appropriate because ongoing air leak can progress to inadequate ventilation and potential pneumothorax despite a functioning drainage setup. Assessing for subcutaneous emphysema or drainage amount can provide additional data, but it does not address the immediate concern of an unresolved air leak that may require medical or surgical intervention.

Question 15

The nurse is preparing the teaching plan for a group of parents about risks to toddlers. The nurse plans to explain proper communication in the event of accidental poisoning. The nurse should plan to tell the parents to first state what substance was ingested and then what information should be the priority for the parents to communicate?

Accepted Answer

Answer reason: Poison control and emergency clinicians must rapidly estimate toxic dose and select interventions that are weight-based (e.g., decontamination decisions and antidote dosing). After identifying the substance, the child’s age and weight most directly determine risk severity and immediate management. Immunization/allergy history does not guide acute poisoning stabilization, and parent contact information is secondary once a call is connected. Time of ingestion and bringing the container are important details, but they do not supersede the need for weight-based risk and treatment calculations.

Question 16

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

Accepted Answer

Answer reason: Frequent swallowing can indicate blood trickling into the throat even when obvious bleeding is not seen, making close monitoring a key nursing safety action. Supine positioning increases aspiration risk and is not preferred when the child is emerging from anesthesia and may have secretions. Using a straw is avoided because suction/negative pressure can dislodge clots and precipitate bleeding, while routine ice cream “every 2 hours” is not the primary immediate postoperative safety priority.

Question 17

A 6 month-old infant who is being treated for developmental dysplasia of the hip has been placed in a hip spica cast. The nurse should teach the parents to?

Accepted Answer

Answer reason: Checking the feet for swelling helps detect developing edema and impaired venous return, which can precede more serious ischemic complications and requires prompt provider notification and possible cast adjustment. It is more urgent in the first 24–48 hours when swelling is most likely to increase. Rubbing the skin for itching risks skin breakdown and introducing objects under the cast can cause pressure injury; turning schedules are helpful but do not replace circulation monitoring.

Question 18

The client who is receiving enteral nutrition through a gastrostomy tube has had 4 diarrhea stools in the past 24 hours. The nurse should?

Accepted Answer

Answer reason: g., antibiotics, sorbitol-containing liquid meds, magnesium-containing antacids, prokinetics) and is an important reversible cause to identify early. Assessing the medication profile targets an underlying etiology rather than masking symptoms and helps prevent dehydration and electrolyte imbalance. Increasing the infusion rate can worsen osmotic diarrhea and intolerance. Skin protection is supportive care but does not address the likely cause and should not be the primary action when a modifiable trigger may be present.

Question 19

While assessing an Rh positive newborn whose mother is Rh negative, the nurse recognizes the risk for hyperbilirubinemia. Which of the following should be reported immediately?

Accepted Answer

Answer reason: A value of 12 mg/dL in this high-risk context is concerning because hemolytic disease can cause bilirubin to increase quickly and reach treatment thresholds earlier than physiologic jaundice. Jaundice appearing after 24 hours can still be significant, but a quantified elevated bilirubin level drives immediate management decisions more directly. A hematocrit of 55% is within expected newborn range, and a positive direct Coombs supports immune-mediated hemolysis but does not by itself indicate the current severity or need for immediate treatment without the bilirubin trend/level.

Question 20

The school nurse is called to the playground for an episode of mouth trauma. The nurse finds that the front tooth of a 9 year-old child has been avulsed ("knocked out"). After recovering the tooth, the initial response should be to?

Accepted Answer

Answer reason: The tooth should be handled by the crown and gently rinsed if dirty, then promptly reinserted into the socket when feasible. Transporting the tooth dry in a plastic bag increases desiccation and reduces reimplantation success. Handling the root damages periodontal ligament fibers, and delaying reimplantation because of bleeding is inappropriate because bleeding can be controlled after rapid replacement.

Question 21

Which of the following is the most important nursing order in a client with major head trauma who is about to receive bolus enteral feeding?

Accepted Answer

Answer reason: Bolus enteral feeds deliver a rapid carbohydrate load, increasing risk for significant glucose excursions that worsen outcomes in critically ill and neurologically injured patients. Close glucose monitoring allows timely insulin adjustment and helps prevent osmotic diuresis, dehydration, and secondary brain injury from metabolic derangements. Albumin reflects longer-term nutritional status and is not an immediate safety risk before a bolus, and intake/output is important but less time-sensitive than preventing acute dysglycemia during feeding initiation.

Question 22

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

Accepted Answer

Answer reason: A spare inner cannula allows rapid removal and replacement when the existing cannula becomes occluded, restoring airflow quickly while further suctioning/cleaning is arranged. Humidification helps secretion management but does not provide an immediate remedy for a blocked trach. A tracheostomy brush is not an emergency airway rescue item and is not relied on for rapid obstruction management at the bedside.

Question 23

A nurse is teaching a newly diagnosed patient with type 1 diabetes mellitus about insulin administration. Which statement by the patient indicates a need for further teaching?

Accepted Answer

Answer reason: Type 1 diabetes requires basal insulin to prevent hyperglycemia and ketosis even when oral intake is reduced, especially during illness when counter-regulatory hormones raise glucose. Skipping insulin on sick days increases risk of diabetic ketoacidosis, dehydration, and electrolyte derangements. Sick-day management typically includes continuing insulin (often with dose adjustment), frequent glucose/ketone monitoring, maintaining hydration and carbohydrates as tolerated, and contacting the provider for persistent hyperglycemia or ketones. The other statements reflect standard safe self-management practices to reduce injection complications, detect hypo/hyperglycemia, and treat hypoglycemia promptly.

Question 24

An infant with congestive heart failure is receiving diuretic therapy at home. Which of the following symptoms would indicate that the dosage may need to be increased?

Accepted Answer

Answer reason: A rapid increase in weight in an infant is a sensitive home indicator of accumulating total body water and deteriorating volume status, suggesting inadequate diuresis. In contrast, decreased blood pressure and bradycardia are more consistent with excessive diuresis or other hemodynamic compromise rather than a need to increase a diuretic. Respiratory slowing is not a typical trigger to escalate diuretics; tachypnea/increased work of breathing from pulmonary congestion would be more expected in worsening CHF.

Question 25

A client with a history of chronic acid reflux presents to the clinic reporting difficulty swallowing and unintentional weight loss over the past month. What is the nurse’s priority action?

Accepted Answer

Answer reason: Progressive dysphagia and unintentional weight loss are alarm symptoms that suggest a serious complication of chronic GERD (e.g., stricture or malignancy) requiring prompt diagnostic evaluation such as endoscopy. The priority nursing action is escalation to the provider to ensure timely workup and prevent delayed diagnosis and worsening obstruction/nutritional compromise. Comfort or lifestyle measures for reflux are not appropriate as first-line responses when red flags are present. Assessing bowel patterns does not address the immediate risk associated with swallowing difficulty and weight loss.

Question 26

A patient received surgery and chemotherapy for colon cancer, completing therapy 3 months previously, and she is now in remission. At a follow-up appointment, she complains of fatigue following activity and difficulty with concentration at her weekly bridge games. Which of the following explanations would account for her symptoms?

Accepted Answer

Answer reason: Chemotherapy commonly suppresses bone marrow, reducing red blood cell production and oxygen-carrying capacity. This leads to exertional fatigue and decreased cognitive performance (eg, poor concentration) due to tissue hypoxia and reduced cerebral oxygen delivery. Immunosuppression primarily manifests as infection risk (fever, frequent infections) rather than isolated fatigue with cognitive slowing. While depression or dehydration can cause fatigue, the history of recent chemotherapy makes treatment-related anemia the most direct and test-relevant explanation.

Question 27

The nurse is giving discharge teaching to a client trseven (7) days post myocardial infarction. He asks the nurse why he must wait six (6) weeks before having sexual intercourse. What is the best response by the nurse to this question?

Accepted Answer

Answer reason: " Sexual activity after MI is guided by functional capacity because it correlates with the cardiovascular demand of intercourse. Being able to climb two flights of stairs without angina, undue dyspnea, or marked fatigue indicates adequate cardiac reserve and lower risk of ischemia/arrhythmia with similar exertion. This response provides an objective, patient-centered self-assessment rather than a vague timeframe or reassurance. Advising alcohol is unsafe because it can worsen hypotension, impair judgment, and interact with cardiac medications, and a walking program alone does not directly define readiness for intercourse.

Question 28

During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to?

Accepted Answer

Answer reason: Caffeine can promote diuresis and vasodilation-related symptoms in some patients and may worsen palpitations, which can aggravate lightheadedness in cardiomyopathy. Advising avoidance of caffeine supports more stable intravascular volume and reduces symptom provocation while the provider evaluates the hemodynamic change. “Restrict fluids” risks worsening hypotension, and “force fluids” is unsafe in cardiomyopathy because excessive intake can precipitate fluid overload and heart failure exacerbation.

Question 29

You are caring for patient who has a burn to the knee. The patient has just completed an autograft and grafting to the burn site. Which of the following orders prescribed is appropriate for this patient?

Accepted Answer

Answer reason: ” Immobilizing the knee reduces movement-related disruption and lowers the risk of graft failure, bleeding, and new tissue trauma. Early ambulation or bathroom privileges increase joint flexion/extension and friction at the graft site, which can dislodge the graft. Keeping the limb dependent would also worsen edema and venous congestion, impairing perfusion and oxygen delivery needed for graft survival.

Question 30

The nurse is assessing a client with infectious mononucleosis. Which of the following findings would require immediate follow-up?

Accepted Answer

Answer reason: Left upper quadrant pain can indicate splenic capsular stretching, infarction, or impending/actual rupture and warrants immediate assessment and activity restriction guidance. The other findings listed (fatigue/somnolence, exudative tonsillitis, and high fever) are typical manifestations that usually receive symptomatic management unless accompanied by airway compromise or hemodynamic instability. Because early recognition of splenic complications prevents catastrophic hemorrhage, this symptom is the priority follow-up.

Question 31

The nurse is caring for a 9-year-old male with glomerulonephritis that develops gross hematuria in the morning. The patient's vital signs are stable. Which of the following nursing interventions should the nurse implement?

Accepted Answer

Answer reason: With stable vital signs and no evidence of urinary obstruction or shock, supportive care and monitoring are the safest immediate nursing action. Urinary catheters (with or without irrigation) increase infection risk and are not indicated unless there is urinary retention/obstruction or clot retention. An IV fluid bolus can worsen fluid overload and hypertension in glomerulonephritis and should be avoided unless there are clear signs of hypovolemia.

Question 32

The nurse cares for a client who has undergone a tonsillectomy. The nurse is most concerned about which postoperative finding?

Accepted Answer

Answer reason: Frequent swallowing is a classic early sign of bleeding, as blood trickles down the throat and is swallowed rather than visibly expectorated. This finding warrants immediate assessment of the oropharynx, vital signs, and notification of the provider with readiness for airway and bleeding management. In contrast, sore throat, nausea, and reduced appetite are common expected postoperative effects and are usually managed symptomatically unless severe or worsening.

Question 33

A client is prescribed prolonged bed rest after surgery. Which complication does the nurse expect to prevent by teaching this client to avoid pressure on the popliteal space?

Accepted Answer

Answer reason: Pressure in the popliteal space can further impede venous return behind the knee, worsening stasis and clot risk. A thrombus originating in the leg can embolize to the pulmonary arteries, producing a potentially fatal pulmonary embolism. Cerebral or coronary embolic events are less directly linked to lower-extremity venous thrombosis, and dry gangrene is primarily an arterial perfusion problem rather than a venous stasis complication.

Question 34

When preparing a client for discharge after surgery for a CABG, the nurse should teach the client that there will be?

Accepted Answer

Answer reason: Saphenous vein harvesting disrupts venous and lymphatic drainage, so dependent swelling of the donor leg can occur and may worsen transiently with increased activity, improving with elevation and compression as instructed. In contrast, ongoing incision drainage is not an expected discharge finding and can indicate infection or dehiscence. Persistent or high fever is not expected and should prompt evaluation rather than being normalized as routine recovery.

Question 35

A patient is being discharged after the insertion of a permanent pacemaker. Which statement made by the patient indicates an understanding regarding appropriate self-care?

Accepted Answer

Answer reason: ” Post–pacemaker discharge teaching emphasizes monitoring for device malfunction or inadequate cardiac output by routinely checking heart rate and rhythm trends. Daily pulse checks with documentation help the patient recognize bradycardia, irregularity, or rates below the programmed lower limit and prompt timely follow-up. Early after implantation, patients should avoid excessive arm/shoulder movement on the affected side rather than doing routine stretches that could dislodge leads. Household appliances like microwave ovens and electric blankets are generally safe with modern pacemakers when used properly, so eliminating them reflects misunderstanding.

Question 36

The LPN is caring for a patient who will be undergoing electroconvulsive therapy (ECT). Of the following, which one requires additional intervention before the procedure?

Accepted Answer

Answer reason: ECT is performed under short-acting anesthesia with a neuromuscular blocker, so reliable IV access must be maintained for induction agents, emergency medications, and fluid support. Removing the IV increases procedural risk because immediate pharmacologic intervention may be needed for airway, hemodynamic instability, or prolonged seizure activity. Being NPO for 6–8 hours and removing jewelry are appropriate pre-procedure safety steps to reduce aspiration and injury risk. Pre-therapy medications given as ordered can be correct depending on the regimen, but loss of IV access is a clear safety problem requiring correction before transport/procedure.

Question 37

A client is being admitted for problems with Ménière's disease. What is most important for the nurse to assess to promote the client’s safety?

Accepted Answer

Answer reason: Knowing the typical onset pattern and severity helps the nurse anticipate when supervision, fall precautions, and activity restriction are most needed. This assessment also guides urgency of interventions (e.g., assistance with ambulation, safe environment during acute vertigo) and monitoring for injury. Diet and hearing assessment are important for long-term management and baseline status, but they are less directly tied to immediate fall-risk prevention during hospitalization.

Question 38

The nurse administers an air enema to a 5-month-old infant to reduce a suspected intussusception. After the air enema the infant passes a light brown stool. Which of the following interventions will the nurse implement first?

Accepted Answer

Answer reason: A successful reduction of intussusception is often followed by passage of normal-appearing stool as bowel perfusion and motility return, and light brown stool is not an alarming finding. The priority is to recognize expected post-procedure outcomes versus signs of complications such as recurrent colicky pain, vomiting, abdominal distention, lethargy, or bloody “currant jelly” stools. Testing for occult blood or sending stool cultures is not indicated based solely on a normal-colored stool without infectious symptoms. Provider notification is reserved for abnormal findings or deterioration suggesting recurrence or perforation, not for an expected stool color change.

Question 39

An 8-month-old infant is scheduled for a balloon angioplasty of a congenital pulmonic stenosis in the cardiac catheterization laboratory. Which finding should the nurse report to the health care provider (HCP) that could possibly delay the procedure?

Accepted Answer

Answer reason: A cath/angioplasty often requires anticoagulation and careful hemodynamic management, so an elevated hematocrit may need treatment (e.g., hydration/partial exchange depending on cause/severity) before proceeding for safety. A loud murmur is expected with pulmonic stenosis and is not, by itself, a reason to postpone. Being NPO for 4 hours is typically acceptable for breast milk (and close to standard fasting windows), and diaper rash generally does not increase procedural risk unless there is systemic infection or skin breakdown at an access/monitoring site.

Question 40

The nurse is caring for a client immediately following hypophysectomy. The nurse should position the client?

Accepted Answer

Answer reason: Elevating the head of bed supports cerebral venous return and helps limit postoperative edema and bleeding in the surgical area. It also decreases pressure at the operative site, which is important after transsphenoidal approaches where a CSF leak can occur. Positions that place the head lower than the body can increase venous congestion and intracranial pressure, worsening complications.

Question 41

A 70-year-old patient diagnosed with testicular cancer has had testicular surgery. On the day of discharge the nurse gave him instructions and told him correctly that?

Accepted Answer

Answer reason: Fever after testicular surgery can indicate wound infection, abscess, or systemic infection and requires timely evaluation and possible antibiotics. The other statements are not universally required discharge instructions and are overly restrictive without individualized provider orders. Monitoring for and reporting infection signs is the safest, highest-yield discharge guidance for this scenario.

Question 42

A client returns to the unit after undergoing a right mastectomy procedure. What is the priority nursing action after the initial recovery period?

Accepted Answer

Answer reason: After mastectomy, early, gentle range-of-motion helps prevent shoulder stiffness, contractures, and impaired upper-extremity function from protective guarding and reduced mobility. It also supports lymphatic drainage and reduces risk of lymphedema when performed as prescribed, making it a key complication-prevention priority once the client is stable. Ambulation is beneficial for general postoperative recovery, but it is less targeted to the procedure-specific risk of ipsilateral shoulder immobility. Cold compresses are not a routine priority intervention after mastectomy and may be inappropriate depending on incision/drain management, and fluid restriction has no standard indication in this context.

Question 43

A nurse is caring for a client who is 72 hours postpartum and reports fever, chills, and lower abdominal pain. Which of the following actions should the nurse prioritize?

Accepted Answer

Answer reason: Fever, chills, and lower abdominal pain at 72 hours postpartum are concerning for postpartum endometritis, a potentially serious uterine infection that can progress to sepsis if not promptly treated. The nurse’s priority is rapid escalation for medical evaluation and orders (cultures, broad-spectrum IV antibiotics, and further assessment), since definitive antimicrobial therapy depends on provider-directed management. While antibiotics are essential, this option is only correct if they are already prescribed and available; the immediate priority with new/worsening signs is to obtain timely provider action. Encouraging fluids and ambulation are supportive measures but do not address the time-sensitive risk of systemic infection.

Question 44

A client is admitted to the emergency department with chest pain that is consistent with myocardial infarction based on elevated troponin levels. Heart sounds are normal and vital signs are noted on the client's chart. The nurse should alert the health care provider because these changes are most consistent with which complication?

Accepted Answer

Answer reason: This complication typically presents with hypotension, tachycardia, cool clammy skin, decreased urine output, and possible pulmonary congestion, prompting urgent provider notification. Normal heart sounds make a mechanical pericardial process like tamponade less likely, where muffled sounds and jugular venous distention are expected. Pulmonary embolism more often produces prominent dyspnea/pleuritic pain and hypoxemia, and aortic dissection is suggested by tearing pain with pulse/BP differentials rather than post-MI troponin-driven ischemic presentation.

Question 45

The nurse has taught parents of a 14-year-old male client with mumps and parotitis. Which of the following statements by the parents would require follow-up?

Accepted Answer

Answer reason: " Neck stiffness with vomiting is not an expected, routine symptom of uncomplicated mumps and raises concern for CNS involvement such as meningitis/encephalitis, which requires prompt medical evaluation. Normal home care teaching emphasizes comfort measures (eg, soft foods and fluids) and monitoring for known complications. Testicular pain/swelling appropriately reflects awareness of orchitis risk in postpubertal males and the need to contact the provider. Isolation from an unimmunized infant is also appropriate because mumps spreads via respiratory droplets and is contagious before and after parotid swelling.

Question 46

A nurse is caring for a client diagnosed with deep venous thrombosis (DVT) in the left lower extremity. Which is the appropriate position for the client?

Accepted Answer

Answer reason: The key principle is promoting venous return while minimizing venous stasis and local edema to reduce pain and limit progression of thrombotic complications. Elevation of the affected extremity above heart level decreases hydrostatic pressure, supports venous drainage, and can improve swelling and discomfort. Keeping the leg dependent worsens venous pooling and swelling, and crossing the legs can further impede venous return via vessel compression. This positioning strategy supports comfort and risk reduction while the client is treated (e.g., anticoagulation) and monitored for embolic complications.

Question 47

A client has laryngeal cancer and undergoes a total laryngectomy. The client returns from the operating room (OR) with a nasogastric tube in place. The nurse identifies the NG tube is in place for what reason?

Accepted Answer

Answer reason: After a total laryngectomy, the immediate postoperative period carries high risk for swallowing impairment because operative edema and tissue trauma can disrupt normal swallowing mechanics. Using an NG tube allows enteral nutrition while keeping the client NPO, reducing the chance that oral intake will enter the airway when protective reflexes and coordination are compromised. Incisional pain alone is not an indication for tube feeding because pain can be managed while still allowing oral intake when safe. High-protein needs are real after major surgery, but the primary rationale for the tube at this stage is airway protection and prevention of aspiration until swallowing safety is confirmed.

Question 48

The nurse has received the assignment for the day shift. After making initial rounds and checking all of the assigned clients, which client should the nurse plan to care for first?

Accepted Answer

Answer reason: A client with a white blood cell count of 14,000 mm3 (14×10^9/L) and a temperature of 38.4 °C Fever with leukocytosis is a red-flag for an evolving infection and possible sepsis, which can deteriorate quickly without prompt assessment and intervention. This client needs immediate focused assessment (vitals trend, potential source), timely cultures/diagnostics as ordered, and early treatment escalation to prevent complications. The postoperative client who just received an opioid does require monitoring for sedation/respiratory depression, but the stem lacks signs of instability and this is a predictable, routine post-medication check. The ambulatory steady-gait client and the client awaiting initial crutch training are stable and can safely be seen after higher-risk physiologic concerns are addressed.

Question 49

A postpartum client who delivered 12 hours ago reports feeling dizzy and lightheaded when she stands up. What is the nurse’s initial action?

Accepted Answer

Answer reason: Postpartum dizziness on standing can signal hypovolemia and evolving shock, and early postpartum hemorrhage is a time-critical complication within the first 24 hours after delivery. The priority nursing action is to rapidly assess for excessive bleeding (amount of lochia, uterine tone/bogginess, clots), vital signs trends, and other signs of circulatory compromise so that escalation and treatment can occur immediately. Encouraging fluids or simply repositioning may temporarily reduce symptoms but can delay recognition of a potentially life-threatening cause. Checking BP can support the assessment, but the highest-risk diagnosis to rule out first in this context is hemorrhage.

Question 50

A community care nurse is assessing risk for pneumonia in a gerontological population. Which of the following clients would have the lowest risk for developing pneumonia?

Accepted Answer

Answer reason: Smoking damages mucociliary clearance and predisposes to lower respiratory infections. Prior cerebrovascular accident commonly causes dysphagia and weak cough, increasing aspiration pneumonia risk. Homelessness with alcohol abuse increases risk through malnutrition, poor access to care/vaccination, impaired immunity, and aspiration during intoxication; isolated atrial fibrillation is comparatively less directly linked to pneumonia development.

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

Potential for Complications NCLEX Practice Test

Continue Learning