Question 1

A client with a pituitary tumor has had transsphenoidal hypophysectomy. Which of the following interventions would be appropriate for this client?

Accepted Answer

Answer reason: After transsphenoidal pituitary surgery, priority nursing care is to reduce intracranial pressure and minimize risk of CSF leak/bleeding through the nasal/surgical pathway. Elevating the head promotes venous drainage from the head and decreases edema at the operative site, supporting neurologic safety. Positions that increase venous congestion or intracranial pressure (e.g., Trendelenburg) are inappropriate. Maneuvers that raise intrathoracic pressure (forceful coughing, Valsalva) can also increase ICP and disrupt the surgical repair, so they should be avoided or minimized.

Question 2

A nurse is beginning to care for a client in labor. The physician has prescribed an IV infusion of Pitocin. The nurse ensures that which of the following is implemented before initiating the infusion?

Accepted Answer

Answer reason: Establishing continuous fetal heart rate and contraction monitoring before starting the infusion allows early detection of late decelerations, bradycardia, or excessive contraction patterns so the infusion can be promptly reduced or stopped and intrauterine resuscitation initiated. This is a high-risk medication in labor where the most immediate complication to prevent is fetal compromise. Bed rest is not a prerequisite for safe administration, antibiotics are unrelated unless an infection indication exists, and a code cart at bedside is not the standard preparatory safety measure for routine oxytocin induction/augmentation.

Question 3

Mr. Rodriguez is seen by a visiting nurse three times a week at his home. He suffers from end stage renal disease. A new RN goes to Mr. Rodriguez's home to provide care and notices a few medications not prescribed by his provider. Which of the following medications would the RN be most concerned about?

Accepted Answer

Answer reason: Hyperkalemia can precipitate life-threatening dysrhythmias and cardiac arrest, making any non-prescribed potassium intake a high-risk complication. A large daily oral potassium dose increases risk further because the body has limited ability to buffer or eliminate the excess. In contrast, acetaminophen at modest doses is generally preferred over NSAIDs in kidney disease, and the listed fish oil and low-dose PRN diphenhydramine are typically less immediately hazardous than potassium loading.

Question 4

The nurse is caring for a client who has thrombocytopenia. Which of the following findings would require immediate follow-up?

Accepted Answer

Answer reason: A decreased level of consciousness is an emergent red flag because bleeding in the brain can progress rapidly and requires immediate assessment and intervention. By comparison, petechiae and minor mucosal bleeding are common manifestations of low platelets but are typically less immediately dangerous than suspected CNS bleeding. Hematuria indicates internal bleeding and warrants prompt evaluation, but acute neurologic decline is higher priority due to airway/brain perfusion risk and potential for irreversible injury.

Question 5

A nurse in the newborn nursery prepares to admit a newborn infant with spina bifida, myelomeningocele type. Which nursing action is most important for the care of this infant?

Accepted Answer

Answer reason: A bulging anterior fontanel is an early, clinically actionable sign of increased intracranial pressure in a newborn and signals the need for urgent evaluation and intervention (e.g., imaging, neurosurgical management). Temperature, blood pressure, and urine specific gravity are important baseline/ongoing assessments, but they are less specific for the most serious, time-sensitive complication expected with this condition. Prioritizing surveillance for neurologic deterioration best addresses immediate risk to life and neurologic function.

Question 6

A nurse is preparing to suction a tracheotomy on an infant. The nurse prepares the equipment for the procedure and turns the suction to which setting?

Accepted Answer

Answer reason: A setting around 80–100 mm Hg is commonly recommended for infant tracheostomy/airway suctioning, balancing secretion removal with tissue safety. This value is high enough to effectively clear secretions while limiting negative-pressure injury and vagal stimulation. Higher settings such as 110–120 mm Hg increase the risk of airway damage and oxygen desaturation, while 60 mm Hg may be insufficient to remove secretions effectively.

Question 7

The nurse is assessing a client immediately following a thoracentesis. The nurse recognizes that the most common complication following this procedure is a?

Accepted Answer

Answer reason: Thoracentesis involves inserting a needle into the pleural space, so the most frequent immediate risk is inadvertent lung puncture or introduction of air, leading to loss of negative intrapleural pressure. This causes acute pleural air accumulation with sudden dyspnea, pleuritic chest pain, decreased/absent breath sounds on the affected side, and possible oxygen desaturation. The nurse’s priority post-procedure assessment is to detect this early (vital signs, respiratory status, and prompt follow-up chest x-ray as ordered) because it can rapidly progress, including to tension physiology. Pneumonia is typically a later infectious complication, not the most common immediate one, and pleural effusion is usually the condition being treated rather than a typical post-procedure complication.

Question 8

The nurse is caring for a client who had a thoracentesis 1 hour ago. Which assessment finding should the nurse report immediately?

Accepted Answer

Answer reason: After thoracentesis, the priority is early recognition of complications that threaten ventilation and oxygenation. Acute dyspnea with asymmetric chest movement suggests an air leak causing pneumothorax and possible lung collapse on the affected side. This can rapidly progress to respiratory distress (and potentially tension physiology), requiring immediate provider notification and intervention (e.g., oxygen, chest imaging, possible chest tube). The other findings listed are expected/normal post-procedure assessments and are not immediately alarming.

Question 9

A postoperative patient is at risk for developing deep vein thrombosis (DVT). The nurse is evaluating the patient's risk factors for DVT. Which of the following patient characteristics should the nurse identify as increasing the risk for DVT?

Accepted Answer

Answer reason: Venous stasis is a major driver of postoperative DVT formation, and immobility reduces calf-muscle pumping that normally promotes venous return. Prolonged time in bed therefore directly increases clot risk and is a key modifiable nursing-identified factor. The other findings listed are within typical adult reference ranges and do not independently raise thrombosis risk in this context. Post-op prevention focuses on early ambulation and mechanical/pharmacologic prophylaxis for patients with immobility-related risk.

Question 10

Which postoperative client requires immediate intervention?

Accepted Answer

Answer reason: Expected adult urine output is about 30 mL/hr (or ~0.5 mL/kg/hr), so 15 mL/hr is significantly low and warrants immediate evaluation of volume status, hemodynamics, and catheter patency. Incisional pain and mild nausea are common, expected postoperative findings that are typically managed with routine analgesics/antiemetics rather than emergent actions. Requesting ice chips is generally a comfort measure and is not inherently dangerous unless contraindicated by NPO status or aspiration risk.

Question 11

The nurse is caring for a client following cervical spinal surgery. Which of the following assessments would require follow-up?

Accepted Answer

Answer reason: Post–cervical spine surgery patients are at risk for airway and esophageal complications from soft-tissue edema or an expanding hematoma, which can rapidly progress to obstruction. New dysphagia—especially with liquids—can signal evolving pharyngeal/laryngeal swelling or recurrent laryngeal nerve involvement and warrants prompt assessment and provider notification. In contrast, mild incisional soreness and scant dressing drainage are common expected postoperative findings. Preserved active arm movement suggests no new cervical cord/nerve root compromise and is generally reassuring rather than urgent.

Question 12

A nurse is caring for a client who has paraplegia as a result of a spinal cord injury. Which rehabilitation plan will be most effective for this client?

Accepted Answer

Answer reason: Early rehabilitation planning after spinal cord injury supports prevention of secondary complications and maximizes functional recovery by integrating mobility training, skin care, bowel/bladder programs, and adaptive strategies from the start. Initiating the plan on admission promotes realistic goal-setting, interdisciplinary coordination, and timely patient/family education, which improves adherence and outcomes. Assuming rehabilitation can be minimal because the client will return to former activities ignores the permanent functional changes associated with paraplegia and risks deconditioning and complications. Planning solely for long-term care also conflicts with the core rehab goal of maximizing independence and self-management wherever possible.

Question 13

What is a basic concept associated with rehabilitation that the nurse should consider when formulating discharge plans for clients?

Accepted Answer

Answer reason: Rehabilitation planning is a proactive nursing process aimed at preventing functional decline and optimizing recovery after illness or injury. Any health problem can create actual or anticipated limitations in mobility, self-care, cognition, or endurance, so the nurse should screen all clients for current and future rehab needs during discharge planning. This approach supports early intervention (e.g., PT/OT referrals, assistive devices, home safety planning) to reduce complications such as deconditioning, falls, and readmission. A common trap is assuming only certain “specialty” populations require rehabilitation; in reality, rehabilitation principles apply broadly across conditions and settings.

Question 14

A client with a dysrhythmia is admitted to telemetry for observation. In the morning the client asks for a cup of coffee. What is the nurse's best response?

Accepted Answer

Answer reason: "Coffee has caffeine that can affect your heart. It should be avoided." Caffeine is a cardiac stimulant that can increase sympathetic activity, raising heart rate and myocardial irritability, which may precipitate or worsen dysrhythmias. This response gives a clear physiologic rationale tied to the client’s condition and promotes risk reduction while the patient is on telemetry observation. It is more therapeutic and educational than a vague statement about “hot drinks,” which incorrectly implies temperature is the problem. It also avoids offering tea as a substitute without clarification, since many teas contain caffeine as well.

Question 15

After abdominal surgery a client suddenly reports numbness in the right leg and a "funny feeling" in the toes. What should the nurse do first?

Accepted Answer

Answer reason: New unilateral postoperative leg numbness/paresthesia suggests an acute neurovascular compromise (e.g., impaired perfusion from thrombosis/arterial occlusion or compressive injury) that requires rapid escalation rather than routine comfort measures. Keeping the client in bed minimizes movement that could worsen an evolving clot/ischemia and supports prompt assessment and intervention. Elevation, rubbing the leg, or encouraging ambulation could delay definitive evaluation and may increase risk (e.g., dislodging a thrombus or worsening ischemia). The safest first nursing action is to stop activity and immediately notify the provider for urgent neurovascular assessment and further orders.

Question 16

To decrease the incidence of aspiration of gastric contents in a child hospitalization with severe burns, the nurse should position the head?

Accepted Answer

Answer reason: Severe burns are associated with stress-related gastric hypersecretion and decreased GI motility, increasing the likelihood of regurgitation and aspiration even outside of feeding times. Continuous elevation to about 45° provides the most consistent reduction in reflux/aspiration risk compared with positioning only during meals. A common pitfall is elevating only during feeding; this leaves the child unprotected during periods of sedation, fatigue, or emesis when aspiration can still occur. Consistent semi-Fowler positioning also supports respiratory mechanics, which is beneficial in critically ill burn patients.

Question 17

The nurse reviews the care needs for a group of postpartum clients. Which client does the nurse identify as being most at risk for developing postpartum hemorrhage?

Accepted Answer

Answer reason: Client who delivered a 9 lb, 8 oz (4.3 kg) newborn. Postpartum hemorrhage is most commonly caused by uterine atony, where the uterus fails to contract effectively after delivery, allowing continued bleeding from uterine vessels. Delivering a macrosomic infant overdistends the uterus, increasing the likelihood of poor uterine tone and atony in the immediate postpartum period. An episiotomy increases risk for localized perineal bleeding/hematoma but is generally less likely than uterine atony to cause major hemorrhage. Breast engorgement is unrelated to uterine tone, and needing help with fundal massage indicates an intervention need but is not an independent predisposing risk factor compared with uterine overdistension.

Question 18

A nurse is caring for a client who has diabetes mellitus. The client's blood glucose level is 320 mg/dL and arterial pH is 7.2. Which of the following nursing interventions is the highest priority for this client?

Accepted Answer

Answer reason: 2 suggests diabetic ketoacidosis with significant metabolic acidosis and high risk for life-threatening electrolyte shifts, especially potassium abnormalities. Potassium may initially appear elevated but rapidly drops once insulin and fluids are started, and either extreme can precipitate dangerous dysrhythmias. Continuous cardiac monitoring is therefore an immediate safety intervention to detect and treat arrhythmias early while definitive therapy is initiated. Blood cultures are only prioritized when infection is strongly suspected and do not address the most imminent complication here. Education and fall-risk assessment are important but are not the first priority during an acute, unstable metabolic emergency.

Question 19

A client with liver cirrhosis begins to drain bright red blood through the nasogastric tube. Which is the priority nursing action?

Accepted Answer

Answer reason: Bright red blood in an NG tube indicates an acute upper GI hemorrhage requiring rapid stabilization of oxygen delivery and coagulation. Cirrhosis commonly causes thrombocytopenia (splenic sequestration) and decreased hepatic synthesis of clotting factors, so replacing platelets and clotting factors with FFP addresses the immediate life-threatening coagulopathy while other definitive measures are arranged. Vitamin K can help only if clotting-factor deficiency is due to impaired vitamin K–dependent factor activation and is not fast enough as the sole priority in active brisk bleeding. Folic acid and ferrous sulfate are supportive for chronic anemia and do not treat acute hemorrhage.

Question 20

A nurse is caring for a client following a thyroidectomy. Which of the following findings should the nurse report immediately?

Accepted Answer

Answer reason: Perioral/finger tingling and muscle twitching are early signs of tetany that can progress to laryngospasm and airway compromise, making this an urgent reportable finding. This requires prompt assessment (e.g., Chvostek/Trousseau), serum calcium evaluation, and readiness to administer IV calcium if ordered. By contrast, a mild sore throat and small serosanguinous drainage can be expected postoperative findings, and the listed vital signs are within acceptable limits.

Question 21

A nurse is teaching a client about the incentive spirometer. Which of the following statements should the nurse include in the teaching?

Accepted Answer

Answer reason: ” Optimal use of an incentive spirometer requires maximizing lung expansion to prevent atelectasis and postoperative pulmonary complications. Upright positioning improves diaphragmatic excursion and ventilation distribution, helping the client achieve a slow, sustained inspiration to the target volume. Using it “4 times a day” is typically insufficient; teaching usually emphasizes frequent use (e.g., multiple times per hour while awake) based on orders/policy. The instruction to “blow…hard and fast” is incorrect because incentive spirometry is inhalation-based and should be slow and controlled, not forceful exhalation.

Question 22

The nurse is teaching a client newly diagnosed with von Willebrand disease. Which of the following information should the nurse include?

Accepted Answer

Answer reason: ” Von Willebrand disease causes impaired platelet adhesion and reduced clot stabilization, increasing risk for mucocutaneous bleeding and menorrhagia. Teaching should emphasize early recognition of abnormal bleeding and when to seek care to prevent significant blood loss and complications like anemia. Aspirin and most NSAIDs worsen platelet function and can increase bleeding, making that advice unsafe. Contact sports increase trauma-related bleeding risk and are not made safe by wearing a bracelet. For epistaxis, the head should be leaned forward with firm continuous pressure to the soft part of the nose; leaning back increases aspiration/swallowing of blood and is incorrect.

Question 23

A nurse is caring for a patient who has just returned from surgery with an indwelling urinary catheter in place. Which of the following findings requires immediate intervention by the nurse?

Accepted Answer

Answer reason: A sudden postoperative decline in urine output signals possible acute kidney hypoperfusion (e.g., hypovolemia, shock) or catheter obstruction and must be addressed promptly to prevent acute kidney injury. For most adults, expected output is at least about 0.5 mL/kg/hr; 15 mL/hr is abnormally low and represents an acute change from expected trends. The immediate nursing response includes assessing catheter patency (kinks/dependent loops, occlusion), checking for bladder distention, and evaluating hemodynamics and fluid status with rapid provider notification if perfusion is a concern. In contrast, 60 mL in the first hour is generally adequate, and mild pink urine can occur transiently after instrumentation without indicating urgent instability.

Question 24

The nurse is caring for a 76-year-old female client who was recently prescribed hydrochlorothiazide. Which client finding would be most concerning?

Accepted Answer

Answer reason: This symptom cluster is concerning because it can indicate worsening sodium depletion that may progress to confusion, seizures, or falls in an older adult. Nocturia is an expected diuretic effect and is typically managed with earlier dosing rather than urgent intervention. Photosensitivity rash and mild lipid changes can occur, but they are usually less immediately dangerous than symptomatic electrolyte imbalance.

Question 25

A neonate has a large amount of secretions. After vigorously suctioning the neonate, the nurse should assess for what possible result?

Accepted Answer

Answer reason: In neonates this can quickly slow the heart rate, especially if suctioning is prolonged and causes transient hypoxia. Therefore, the key immediate assessment after suctioning is heart rate for bradycardia and associated oxygenation changes. Tachycardia is less typical in the moment and would be more consistent with pain, agitation, or evolving hypoxia rather than a direct vagal reflex.

Question 26

A nurse is caring for an 8-year-old child who has just undergone tonsillectomy. The child stays sleepy because of the anesthesia but is easily awakened. Which position must the nurse place the child in?

Accepted Answer

Answer reason: Placing the child on the side promotes drainage of secretions and blood and helps maintain a patent airway without the tongue falling back. Supine positioning increases the likelihood of airway obstruction and aspiration if vomiting or bleeding occurs. Trendelenburg is not indicated and can worsen respiratory mechanics and increase aspiration risk.

Question 27

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

Accepted Answer

Answer reason: Rupture can cause sudden massive internal hemorrhage, rapid hypotension, shock, and death, making it the top preoperative concern. Hypertension increases rupture risk but is a risk factor/management issue rather than the catastrophic complication itself. Arrhythmias and diminished pedal pulses may occur with vascular disease, but they are typically less immediately fatal than rupture and do not supersede hemorrhagic shock risk.

Question 28

An elderly patient comes into the emergency department to rule out stroke. On admission, vital signs are pulse 90, blood pressure 150/100, and respirations 20. An IV is run for the patient. Upon reassessment 30 minutes later, vital signs are pulse 78, blood pressure 170/90, and respirations 24 and irregular. What action should the nurse consider taking?

Accepted Answer

Answer reason: Continuing or increasing fluids may worsen cerebral edema and contribute to hypertension in a vulnerable brain. The immediate nursing response should be to consider slowing/stopping the infusion while rapidly escalating care (frequent neuro checks and notifying the provider/rapid response as indicated). Asking how the patient feels delays action, and checking a phenytoin level is unrelated to the current presentation and does not address the acute neurologic risk.

Question 29

Which of the following is a common sign of deep vein thrombosis (DVT) in the postpartum period?

Accepted Answer

Answer reason: This finding is a common bedside clue prompting urgent evaluation and anticoagulation to prevent embolization. Sudden shortness of breath more strongly indicates pulmonary embolism, a complication of DVT rather than a typical presenting leg sign. Fever/chills suggests infection (e.g., endometritis or mastitis), and nausea/vomiting is nonspecific and not a characteristic DVT feature.

Question 30

SITUATION: A nurse is caring for a client with chronic heart failure. Which of the following symptoms should the nurse prioritize monitoring?

Accepted Answer

Answer reason: A 3-lb gain in 24 hours exceeds common thresholds used to trigger urgent assessment and potential therapy adjustment (e.g., diuretics, sodium/fluid restriction reinforcement). The other findings listed are not inherently concerning in a stable CHF client because they reflect normal vital signs or a nonspecific mild symptom. Prioritizing daily weight trends helps detect decompensation earlier than waiting for overt dyspnea or abnormal vital signs.

Question 31

Three hours after a vaginal delivery, the client complains of increased perineal pain. What should the nurse do first?

Accepted Answer

Answer reason: New or worsening perineal pain shortly after vaginal birth can indicate a developing hematoma or worsening edema, which requires assessment before symptom treatment. A focused perineal inspection/palpation helps identify swelling, bruising, firmness, expanding mass, or excessive tenderness that could signal occult bleeding and potential hemodynamic risk. Interventions like ice and prescribed analgesics are appropriate for routine postpartum discomfort, but they can delay recognition of a complication if given first. Immediate assessment also guides whether urgent provider notification and further monitoring (e.g., vitals, bleeding) are needed.

Question 32

The nurse is assessing the patient who is 1 hour post esophagogastroduodenoscopy (EGD). Which finding should the nurse identify as the highest priority to report to the provider?

Accepted Answer

Answer reason: Temperature of 101.5 F (38.6C). Fever shortly after an EGD is an abnormal finding that can signal a developing complication such as infection or GI perforation, both of which require rapid provider evaluation. Early perforation may initially present subtly, and fever can be one of the first systemic signs before overt peritonitis or hemodynamic instability appears. In contrast, mild sore throat is expected from scope irritation, and tolerating ice chips suggests return of swallowing/gag reflex without complication. Adequate clear urine output is not concerning in this context and does not indicate an acute post-procedure complication.

Question 33

A gravida 3 para 2 is admitted to the labor unit. Vaginal exam reveals that the client’s cervix is 8 cm dilated, with complete effacement. The priority nursing diagnosis at this time is?

Accepted Answer

Answer reason: At 8 cm with complete effacement in a multiparous client, labor can progress rapidly, creating immediate risk for an uncontrolled birth. The top priority is preventing maternal and neonatal injury (e.g., fetal head trauma, perineal lacerations, postpartum hemorrhage) by anticipating imminent delivery and ensuring readiness and safety measures. Pain and coping are important but are secondary to the safety threat posed by a likely rapid delivery. Elimination related to anesthesia and dehydration from NPO are not the most time-critical issues in the moment compared with the risk of sudden birth complications.

Question 34

The nurse is assessing a newborn client born vaginally 22 hours ago at 36 weeks gestation. Which of the following findings requires immediate follow-up?

Accepted Answer

Answer reason: Scleral icterus at 22 hours warrants prompt bilirubin measurement and evaluation for blood type incompatibility, bruising/cephalohematoma, infection, and feeding adequacy, with early treatment as indicated. In contrast, soft occipital scalp edema is consistent with caput succedaneum and is typically benign and self-limited. Erythema toxicum and transient mucus gagging/spitting are also common early newborn findings unless accompanied by respiratory distress, persistent choking, or feeding intolerance.

Question 35

After turning and repositioning a client who is intubated, the nurse is having difficulty auscultating breath sounds over the left lung field. What should the nurse do at this time?

Accepted Answer

Answer reason: New unilateral decrease/absence of breath sounds after repositioning an intubated client suggests a potentially serious complication such as endotracheal tube malposition (e.g., right mainstem intubation with diminished left-sided sounds) or acute pneumothorax, both requiring prompt evaluation and intervention. The nurse should escalate immediately so the airway/ventilation can be assessed and corrected using appropriate methods (e.g., verifying tube depth/placement and obtaining diagnostic confirmation) rather than making unprescribed changes. Attempting to pull back the tube is outside typical nursing scope without an order and risks extubation. Increasing ventilator settings or turning the client does not address the primary problem of possible airway displacement or lung complication.

Question 36

The nurse is caring for a client with a basilar skull fracture. Which assessment finding requires immediate follow-up?

Accepted Answer

Answer reason: Temperature 100.9°F (38.3°C) Basilar skull fracture increases the risk of cerebrospinal fluid leakage and subsequent intracranial infection (meningitis), so new fever warrants urgent evaluation. A temperature of 38.3°C is an early, actionable sign that may indicate developing infection and requires prompt provider notification and further assessment (e.g., neurologic status, CSF leak, cultures as ordered). Periorbital and retroauricular ecchymosis are classic expected findings of basilar skull fracture and are important to document and monitor but are not as time-critical as possible infection. Headache can also be expected after head injury; it becomes emergent mainly when accompanied by worsening neurologic signs suggesting rising ICP.

Question 37

Which sign indicates that the need for increased fluid intake would be contraindicated in a patient diagnosed with a hepatic disorder?

Accepted Answer

Answer reason: In this setting, encouraging increased fluid intake can worsen third-spacing, ascites, and peripheral edema, increasing risk for respiratory compromise and other complications. The appropriate nursing judgment is to question orders promoting increased intake and further assess weight trends, I&O, electrolytes, and cardiopulmonary status. In contrast, low blood pressure or increased urine output more often suggest hypovolemia or adequate diuresis rather than fluid excess.

Question 38

The priority nursing intervention after an amniotomy should be to?

Accepted Answer

Answer reason: Amniotomy can cause an acute change in fetal oxygenation due to cord prolapse, cord compression, or rapid shifts in uterine volume, so immediate surveillance for fetal compromise is the safety priority. The earliest and most sensitive bedside indicator of these complications is a change in the fetal heart rate pattern (e.g., bradycardia or variable decelerations). If an abnormal tracing occurs, rapid interventions (maternal repositioning, evaluation for prolapsed cord, stopping oxytocin, and notifying the provider) can be initiated without delay. While observing fluid color and amount provides useful information (meconium, bleeding), these assessments do not supersede promptly confirming fetal well-being after membrane rupture.

Question 39

The nurse is placing a client with chronic kidney disease on a cardiac monitor. What is the reason for this action?

Accepted Answer

Answer reason: Clients with chronic kidney disease have impaired potassium excretion, making hyperkalemia a common and dangerous complication. Elevated serum potassium alters myocardial conduction, producing ECG changes and potentially lethal dysrhythmias (e.g., peaked T waves, widening QRS, ventricular arrhythmias). Continuous cardiac monitoring is a safety intervention to detect rhythm changes early and prompt rapid treatment. Hypertension is common in CKD but does not by itself justify continuous rhythm monitoring as the primary rationale. Cardiac monitoring is not used to determine the need for hemodialysis; dialysis need is guided by labs, symptoms, and volume/uremic status.

Question 40

The nurse is caring for an older adult client with delirium for the third time in the past four months. While reviewing the client's medical record to determine the cause, the nurse should prioritize reviewing the client's?

Accepted Answer

Answer reason: Delirium in older adults is most often precipitated by acute, reversible factors, and medications are among the most common and modifiable triggers. Reviewing the medication list identifies high-risk agents (e.g., anticholinergics, benzodiazepines, opioids), recent additions or dose changes, and polypharmacy/drug–drug interactions that can cause recurrent episodes. This priority step directly guides immediate interventions such as deprescribing, dose adjustment, or substitution and helps prevent further complications. Vital signs can suggest infection or hypoxia, but for recurrent delirium over months, the medication profile is a higher-yield, frequently overlooked cause than baseline measures like height/weight or family history.

Question 41

The nurse is caring for a client with appendicitis experiencing pain. Which pain relief method would be inappropriate for this client?

Accepted Answer

Answer reason: Heat increases local blood flow and can intensify inflammation, which may accelerate appendiceal swelling and raise risk of perforation in suspected appendicitis. Nursing care prioritizes preventing complications while providing comfort, so interventions that could worsen the intra-abdominal inflammatory process are avoided. Nonpharmacologic measures such as rest and relaxation techniques can reduce pain perception without increasing physiologic risk. Cold application may provide some localized analgesia and does not promote vasodilation in the same way as heat.

Question 42

A nurse in a maternal newborn clinic is caring for a client who is at 28 weeks of gestation. The client's blood pressure reading is 148/92 mmHg, compared to her previous reading of 122/78 mmHg. Her Urinary Analysis was positive for protein. Which action should the nurse take first?

Accepted Answer

Answer reason: New-onset hypertension with proteinuria at 28 weeks is concerning for preeclampsia, where the immediate priority is identifying severe features that signal impending eclampsia/HELLP and rapid deterioration. Headache and epigastric/RUQ pain reflect possible cerebral edema and hepatic involvement, which require urgent escalation and potential magnesium sulfate and expedited evaluation. A focused symptom assessment is the fastest, most direct way to determine severity and guide time-critical interventions. Laboratory tests are important but follow the initial rapid assessment for severe symptoms. Dietary advice is inappropriate here, and antihypertensives are typically initiated urgently for severe-range pressures (≥160/110), not this initial non-severe value without first assessing for severe features.

Question 43

A client receives discharge instructions after a diagnosis of multiple myeloma. The nurse makes which statement during discharge teaching?

Accepted Answer

Answer reason: Multiple myeloma and its treatments (e.g., chemotherapy, opioids for bone pain) can cause significant nausea that leads to dehydration, poor intake, and worsening fatigue, which increases risk for complications. Prompt reporting allows timely assessment and antiemetic or regimen adjustments to prevent electrolyte imbalance, malnutrition, and reduced treatment tolerance. Fluid restriction is generally inappropriate because maintaining hydration helps protect renal function and reduce complications from light-chain protein load and hypercalcemia. Complete bed rest is unsafe because it promotes deconditioning and thromboembolic risk; activity is encouraged within safety limits.

Question 44

The nurse is caring for a client with a right radial arterial line. Which finding is most concerning?

Accepted Answer

Answer reason: Cool, pale digits suggest impaired perfusion and require immediate assessment (pulses/cap refill), prompt provider notification, and likely discontinuation of the line to prevent ischemic injury. Mild oozing can occur and is usually managed with reinforced dressing/pressure unless brisk or expanding. A dampened waveform more commonly reflects technical issues (air, clot, kinks, improper leveling) and is typically less urgent than signs of compromised circulation.

Question 45

Your patient just returned from the PACU after a thyroidectomy. Which of the following lab values would the nurse closely monitor?

Accepted Answer

Answer reason: A falling calcium level can quickly lead to neuromuscular excitability and life-threatening complications such as laryngospasm, stridor, seizures, and dysrhythmias. Early detection through close calcium monitoring supports prompt intervention (e.g., IV calcium for symptomatic hypocalcemia) and ongoing assessment for signs like perioral numbness or tetany. While hemoglobin may be checked for bleeding, it is less specific and typically slower to reflect an acute neck hematoma than focused airway/neck assessment plus calcium surveillance. Electrolytes like sodium, potassium, and iron are not the hallmark labs tied to the most characteristic endocrine complication of thyroidectomy.

Question 46

The client with a pelvic fracture developed a fat embolism. The nurse should assess the client for which specific sign?

Accepted Answer

Answer reason: The classic triad includes respiratory distress, neurologic changes, and a petechial rash, with the rash being the most specific distinguishing bedside sign. Petechiae often appear on the chest, axillae, conjunctiva, or oral mucosa due to dermal capillary embolization and thrombocytopenia. Dyspnea and delirium can occur but are less specific and overlap with other post-trauma complications such as PE, hypoxia from atelectasis, or medication effects.

Question 47

A client has just undergone a stapedectomy. How should the nurse position the client?

Accepted Answer

Answer reason: Placing the client on the nonoperative side prevents direct pressure on the surgical ear and reduces the risk of disrupting the dressing or internal ear structures. It also helps minimize postoperative complications such as bleeding and vertigo triggered by unnecessary manipulation or pressure to the affected ear. Positioning on the operative side or prone can increase pressure and movement risk, which is unsafe immediately post-op.

Question 48

A nurse should question an order to irrigate the ear canal in which circumstance?

Accepted Answer

Answer reason: This raises the risk of introducing infection, worsening inflammation, and causing middle-ear complications such as otitis media or labyrinthine irritation with vertigo. The safest nursing action is to question the order and clarify the need for alternative management (e.g., suction/ENT evaluation) when perforation is suspected or confirmed. Ear pain or hearing loss alone are not absolute contraindications without evidence of a perforation, and otitis externa is often managed with topical therapy rather than routine irrigation unless specifically indicated and the membrane is intact.

Question 49

A 2-year-old child with hemophilia who sustains a joint injury is best treated promptly at which location?

Accepted Answer

Answer reason: Many families are taught to administer the prescribed factor concentrate immediately at the first sign of joint bleeding, which makes the home setting the fastest route to definitive therapy. Prompt factor administration limits ongoing bleeding, decreases pain and swelling, and helps prevent chronic joint damage. The emergency department or inpatient care is appropriate if bleeding is severe, uncontrolled, associated with head/neck trauma, or if home infusion is not available, but it is not the fastest routine first step for an isolated joint injury in a trained family.

Question 50

The nurse is aware that which complication is most commonly related to acute otitis media?

Accepted Answer

Answer reason: This is the most frequent complication and is clinically important because persistent effusion can affect speech and language development in children. Eardrum perforation can occur from pressure buildup but is less common than temporary conductive loss and often heals spontaneously. Meningitis is a rare but serious intracranial spread, and tympanosclerosis is typically associated with chronic/recurrent disease rather than a single acute episode.

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

Potential for Complications NCLEX Practice Test

Continue Learning