Question 1

A nurse should expect which finding up to 48 hours after the surgical repair of pyloric stenosis?

Accepted Answer

Answer reason: This is generally expected as long as it is not progressive, bilious, or accompanied by signs of dehydration or obstruction. Oliguria would suggest hypovolemia/dehydration and is not an expected normal finding. Oral aversion is more of a longer-term feeding issue rather than an immediate 48-hour postoperative expectation.

Question 2

Which assessment finding would be a cause for alarm in a client taking finasteride (Proscar)?

Accepted Answer

Answer reason: Azotemia can indicate postrenal failure from severe obstruction, which can progress to hydronephrosis and acute kidney injury if not rapidly addressed. In contrast, breast enlargement is a known adverse effect related to hormonal changes and is usually non-emergent unless associated with a breast mass or severe symptoms. Decreased prostate size reflects the expected therapeutic effect, and flushing is not a key alarming toxicity for this medication.

Question 3

Which symptom may indicate acute rejection of a transplanted kidney?

Accepted Answer

Answer reason: This inflammation commonly presents with local graft tenderness/pain and may be accompanied by decreased urine output, fever, weight gain, and rising creatinine. Increased urine output would be more consistent with improved graft function or post-obstructive diuresis rather than rejection. A decreased WBC count more typically reflects immunosuppressant effects and infection risk, not the inflammatory rejection response.

Question 4

A client diagnosed with acute renal failure voided 260 ml of urine on Tuesday. What is the maximum amount of fluid the client may consume orally on Wednesday?

Accepted Answer

Answer reason: Adding 500 mL to the client’s Tuesday output of 260 mL yields a maximum oral intake of 760 mL for Wednesday. This strategy helps prevent fluid overload complications such as pulmonary edema and hypertension when the kidneys cannot excrete water effectively. Options lower than this do not reflect the standard urine-output-plus-insensible-losses calculation and could lead to unnecessary dehydration risk.

Question 5

The nurse is caring for a preoperative client with an abdominal aortic aneurysm. The client is most at risk for?

Accepted Answer

Answer reason: An abdominal aortic aneurysm is a weakened, dilated arterial segment where the highest-impact threat is sudden loss of vessel integrity with catastrophic hemorrhage. Preoperatively, the nurse’s priority risk focus is early recognition and prevention of factors that increase wall stress (e.g., uncontrolled blood pressure, heavy exertion) because rupture is rapidly fatal. Hypertension can contribute to expansion but is not the primary imminent complication compared with rupture. Diminished pedal pulses may occur if there is distal embolization or occlusive disease, but it is less immediately life-threatening than rupture.

Question 6

A client has undergone ligation and stripping. What is the best intervention for the nurse to implement postoperatively?

Accepted Answer

Answer reason: Compression maintains external pressure on the treated vein bed, reduces postoperative swelling and bruising, and promotes effective circulation in the affected extremity. Prolonged sitting increases venous stasis, and strict bed rest is not preferred because early ambulation with compression is typically encouraged to lower DVT risk. Ice packs may help localized pain and swelling but are adjunctive and do not provide the ongoing venous support needed after this procedure.

Question 7

Immediately after a liver biopsy, which complication should a client be closely monitored for?

Accepted Answer

Answer reason: This complication can rapidly progress to internal bleeding and shock, so close monitoring of vital signs, pain (especially increasing RUQ/shoulder pain), and signs of hypotension is essential right after the procedure. While infection is a possible later complication, it is not the primary immediate threat in the first hours post-biopsy. Mild nausea/vomiting or cramping may occur but are generally less life-threatening than acute bleeding.

Question 8

A 43-year-old client undergoing colon cancer treatment has developed thrombocytopenia. The nurse should assess the client for?

Accepted Answer

Answer reason: Thrombocytopenia increases bleeding risk because platelets are required for primary hemostasis and formation of the initial platelet plug. A key nursing assessment is for signs of bleeding such as petechiae, ecchymoses, gingival bleeding, epistaxis, or blood in urine/stool. New or worsening bruising is a common, visible manifestation of low platelet counts and can signal clinically significant bleeding risk. Diarrhea and thin, brittle hair are more consistent with chemotherapy adverse effects or nutritional issues, and urinary urgency suggests a urinary tract problem rather than impaired clotting.

Question 9

The nurse recognizes that the most appropriate treatment for clients with tumor lysis syndrome is?

Accepted Answer

Answer reason: Tumor lysis syndrome causes rapid release of intracellular contents leading to hyperkalemia, hyperphosphatemia, hyperuricemia, and acute kidney injury from uric acid/calcium phosphate precipitation. Aggressive IV hydration is the cornerstone because it supports renal perfusion and increases urine output to enhance clearance of uric acid, potassium, and phosphate. Antibiotics do not address the metabolic derangements unless there is a separate infection, and transfusing packed RBCs is not a primary treatment for TLS. Giving IV potassium chloride is contraindicated because TLS already predisposes the client to dangerous hyperkalemia and dysrhythmias.

Question 10

The nurse is assessing a client who is admitting for a long bone fracture. Which assessment finding would be noted as a life-threatening complication?

Accepted Answer

Answer reason: This risk is clinically critical because it can rapidly progress to hypoxemia/ARDS, altered mental status, and petechiae, requiring urgent recognition and support. The other listed “emboli” are not recognized, standard post–long bone fracture complications assessed in nursing practice in this way. Prioritizing early identification of this complication aligns with preventing deterioration and respiratory failure.

Question 11

The nurse is assessing a client and determines that which of the following is a risk factor for traction-related complications?

Accepted Answer

Answer reason: Diabetes predisposes to these complications through peripheral neuropathy (reduced protective sensation) and microvascular disease (reduced tissue perfusion), making early skin injury harder to detect and slower to heal. It also increases susceptibility to infection and delays tissue repair, which are key traction-related risks. In contrast, hypertension and coronary artery disease are not specific predictors of traction skin/pin-site complications compared with impaired healing conditions.

Question 12

The nurse is caring for a client who had a stroke and now has residual dysphagia. What is the most appropriate diet for this client?

Accepted Answer

Answer reason: Increasing viscosity slows flow and reduces premature spillage into the pharynx, making swallowing safer than thin liquids. Thin liquids (clear or full) are commonly aspirated because they move too quickly to coordinate an effective swallow. Mechanical soft changes food texture but does not address the high-risk problem of thin-fluid aspiration, so liquid thickening is the safer priority.

Question 13

In caring for a client after cataract surgery, the nurse should notify a physician if the client has which of the following conditions?

Accepted Answer

Answer reason: These conditions require prompt medical evaluation and treatment to prevent permanent vision loss. Mild blurred vision and glare are common early postoperative effects from corneal edema, dilation, or the new intraocular lens adjusting. Itching is more consistent with mild irritation or healing but should be monitored for rubbing risk rather than triggering urgent provider notification by itself.

Question 14

A nurse assesses a client who has episodes of autonomic dysreflexia. Which condition can cause autonomic dysreflexia?

Accepted Answer

Answer reason: Common precipitants include bladder distention, bowel impaction, skin irritation/pressure injuries, or other painful procedures. This option directly reflects the mechanism that initiates the episode and is the key cause nurses must assess for and remove promptly. Headache is typically a manifestation of the hypertensive crisis rather than the precipitating cause, and a lumbar injury is less associated because lesions below T6 usually do not produce this syndrome. Neurogenic shock is a different acute spinal cord complication characterized by hypotension and bradycardia, not episodic hypertension from triggers.

Question 15

The nurse is caring for a client in the immediate postoperative period. The priority of care would include interventions to prevent?

Accepted Answer

Answer reason: Immediate postoperative care prioritizes preventing early respiratory complications caused by anesthesia, opioid analgesia, pain-limited chest expansion, and immobility, all of which reduce alveolar ventilation. Alveolar collapse can develop within hours and is a leading cause of postoperative hypoxemia, so interventions like coughing/deep breathing, incentive spirometry, turning, and early ambulation directly target this risk. Pneumonia is often a downstream complication that becomes more likely when atelectasis and retained secretions persist, making it a later concern rather than the earliest priority. Pneumothorax is not a routine postoperative risk unless specific procedures/trauma or ventilation complications are present, and bronchitis is not the primary immediate threat compared with alveolar collapse.

Question 16

Which nursing diagnosis is most appropriate for a child with rheumatic fever?

Accepted Answer

Answer reason: These symptoms increase the likelihood of falls and other harm, and nursing care prioritizes preventing complications through rest, assistance with mobility, and safety measures. The other options are not broadly characteristic priorities: excess nutrition is not typical, impaired gas exchange is not a defining problem unless there is severe heart failure/pulmonary edema, and delayed growth/development reflects a longer-term pattern rather than the immediate clinical risk during the acute illness.

Question 17

An infant returns from surgery after repair of a cleft palate. What is the priority nursing intervention?

Accepted Answer

Answer reason: Postoperative priority is maintaining airway patency and preventing aspiration from blood and oral secretions after palatal repair. Side-lying positioning promotes drainage out of the mouth rather than pooling in the oropharynx, reducing obstruction and aspiration risk. Routine aggressive suctioning can traumatize the fresh suture line and precipitate bleeding or dehiscence, so it is avoided unless clearly necessary and ordered. A pacifier can place pressure on the operative site and is typically contraindicated after cleft palate repair despite providing comfort.

Question 18

Which aspect is most important for successful management of the child with Reye’s syndrome?

Accepted Answer

Answer reason: Prompt recognition allows immediate measures to reduce intracranial pressure, correct hypoglycemia and metabolic derangements, and provide intensive monitoring/airway support before neurologic deterioration occurs. Antibiotics do not treat the underlying mitochondrial-related hepatic injury and are only indicated for a proven bacterial process. Isolation is not a key intervention because Reye’s syndrome itself is not contagious, and staging may help describe severity but does not replace time-sensitive supportive care.

Question 19

A child is brought to a physician’s office for multiple scratches and bites from a kitten. The nurse would assess the child for which finding?

Accepted Answer

Answer reason: This complication often develops days to weeks after the injury and may be tender and enlarged, sometimes with overlying erythema. While fever can occur, it is less specific than the hallmark lymph node involvement and would not be the most targeted assessment finding. Pruritus and abdominal pain are not the characteristic assessment priority for this exposure.

Question 20

A child weighing 10 kg has a deep partial-thickness burn to 40% of his body surface area. The nurse will titrate the child's I.V. fluids to achieve which hourly urinary outputs?

Accepted Answer

Answer reason: In pediatric burn management, a common target is at least 1 mL/kg/hr. For a 10-kg child, this equals 10 mL/hr, which reflects sufficient renal perfusion without assuming over-resuscitation. The smaller value would suggest under-resuscitation and risk of hypovolemia, while the larger values exceed the minimum goal and are not the standard titration target.

Question 21

A young child sustains a dislocated hip as well as a subcapital fracture. The nurse is aware that the client is at greatest risk for which of the following?

Accepted Answer

Answer reason: In children, compromised perfusion places the femoral head at high risk for ischemia and subsequent bone death, making this the most serious and characteristic complication to anticipate and monitor for. While infection is a general postoperative risk, it is not the complication most specifically linked to this injury pattern. Hemorrhage can occur with orthopedic surgery, but the hallmark limb-threatening/long-term complication from femoral head perfusion loss is the priority risk.

Question 22

Which hip position should be avoided in an 8-month-old infant who has been diagnosed with developmental dysplasia of the hip?

Accepted Answer

Answer reason: Hip extension tends to move the femoral head posteriorly and decreases stable seating in the socket, increasing instability risk. Management aims to keep the hips flexed and abducted (as with a Pavlik harness), which promotes reduction and acetabular development. A common distractor is abduction, but that is typically therapeutic rather than something to avoid in standard DDH positioning guidance.

Question 23

Immediately after a spinal fusion, which restriction is usually put on the child’s activity?

Accepted Answer

Answer reason: Early post-op activity is typically restricted to strict positioning with spinal precautions (often flat/supine with log-rolling for turns) until the surgeon clears progressive mobilization and bracing as indicated. Weight-bearing restrictions are more characteristic of lower-extremity orthopedic procedures rather than a primary spinal stabilization surgery. Allowing unrestricted activity immediately would increase risk for pain, neurologic compromise, and wound/implant complications.

Question 24

A client’s platelet count is 70,000/mm3. The nurse instructs the client to?

Accepted Answer

Answer reason: Thrombocytopenia increases bleeding risk because inadequate platelets impair primary hemostasis and clot formation. With a platelet count of 70,000/mm3, the priority teaching is bleeding precautions to prevent skin and mucosal trauma. An electric razor reduces the chance of cuts compared with a blade, lowering the risk of prolonged bleeding. Avoiding crowds is neutropenia-focused (infection prevention) rather than platelet-focused, and calcium intake or increased fluids do not address hemorrhage prevention.

Question 25

The nurse assesses a client who has a vitamin K deficiency. What should the nurse expect to find upon assessment of this client?

Accepted Answer

Answer reason: Vitamin K is required for hepatic synthesis of several clotting factors (II, VII, IX, X), so deficiency impairs coagulation and increases bleeding tendency. This commonly presents as easy bruising, petechiae, bleeding gums, and prolonged bleeding after minor trauma, making bruising a key assessment finding. Anemia can occur secondary to significant bleeding but is not the most direct or expected initial sign compared with bruising. Hypertension and mental status changes are not typical primary manifestations of isolated vitamin K deficiency.

Question 26

The nurse cares for a client in skin traction. The nurse knows to assess the client frequently for?

Accepted Answer

Answer reason: Skin traction applies continuous pulling force through adhesive straps/boots, which places the client at high risk for pressure injury and impaired tissue perfusion under the device. Frequent neurovascular and skin assessments help detect early redness, blistering, or compromised circulation before full-thickness injury occurs. Pin-site infection is a key concern with skeletal traction, not skin traction, making that option a common distractor. Bowel findings are not the primary, traction-specific complication to monitor compared with skin integrity at pressure points.

Question 27

Which nursing diagnosis is most important for a client receiving enteral tube feedings?

Accepted Answer

Answer reason: Enteral tube feedings create a high-priority airway risk because regurgitation or incorrect tube placement can allow formula to enter the lungs and cause aspiration pneumonia, hypoxia, or respiratory failure. This is an immediate, potentially life-threatening complication, so it takes priority over comfort or education diagnoses. Diarrhea and fluid volume deficit can occur with tube feeds but are typically less rapidly fatal and are managed after airway protection measures are ensured. Nursing care focuses on aspiration prevention (e.g., verifying placement per policy, head-of-bed elevation, monitoring residuals and intolerance signs).

Question 28

The nurse cares for a client after a transphenoidal hypophysectomy. The nurse should monitor for which sign of hemorrhage?

Accepted Answer

Answer reason: Post–transsphenoidal surgery places the client at risk for occult nasopharyngeal bleeding that can drain posteriorly into the throat rather than out the nares. Repeated swallowing is a classic early indicator that blood is trickling down the pharynx and the patient is clearing it unconsciously. Hematuria and hemoptysis would suggest urinary or lower airway bleeding and are not expected complications specific to this procedure. Ear drainage more strongly suggests CSF leak/otorrhea related to skull base involvement rather than hemorrhage after a transsphenoidal approach.

Question 29

A client underwent an abdominal hysterectomy 6 hours ago. The nurse teaches the client to avoid which position?

Accepted Answer

Answer reason: Early after abdominal hysterectomy, positioning should minimize tension on the abdominal incision and reduce risk of bleeding and wound dehiscence. Sitting upright increases abdominal muscle strain and can place greater stress on sutures, especially within the first postoperative hours. Side-lying or lateral recumbent positions support comfort while limiting direct pull on the incision. Supine is also acceptable when aligned and supported, whereas the upright posture is the key position to avoid in this immediate postoperative period.

Question 30

Which leisure activity would the nurse recommend to parents for a school age child with hemophilia?

Accepted Answer

Answer reason: Low-impact exercise supports muscle strength and joint stability, which can reduce hemarthrosis risk. Contact sports and higher-collision activities substantially increase the likelihood of soft-tissue and intracranial bleeding. Swimming is a low-trauma aerobic activity with minimal fall/contact risk, making it the safest choice among the options.

Question 31

An elderly client on bed rest for a week after a bout of pneumonia is in a negative nitrogen balance. Which complication has highest priority?

Accepted Answer

Answer reason: In an elderly client after acute illness and a week of bed rest, this rapidly leads to loss of skeletal and respiratory muscle strength, worsening deconditioning and increasing risk for impaired mobility, delayed recovery, and further pulmonary complications. This is a more immediate, systemic threat than constipation or renal calculi, which are important but generally develop more slowly and are less directly tied to the core problem of protein loss. Vitamin B6 deficiency is not the expected primary complication of negative nitrogen balance compared with protein-energy catabolism affecting muscle.

Question 32

A client is hospitalized with an acute sinus infection. Which assessment made by the nurse indicates serious complications?

Accepted Answer

Answer reason: Neck stiffness suggests inflammation of the meninges and requires urgent evaluation and treatment to prevent neurologic deterioration and sepsis. By contrast, fever, frontal headache, and even periorbital swelling can occur with uncomplicated sinusitis or localized extension, but they do not specifically signal meningeal involvement. The presence of this sign should prompt immediate provider notification and rapid diagnostic workup (e.g., neurologic assessment and cultures as ordered).

Question 33

Which nursing discharge instruction has the highest priority for a client going home with a full leg cast?

Accepted Answer

Answer reason: Teaching the client to promptly recognize and report warning findings (e.g., increasing pain unrelieved by analgesics, numbness/tingling, pallor or coolness, delayed capillary refill, inability to move toes) supports early intervention before compartment syndrome develops. Discharge instructions about activity and weight-bearing are important but are less immediately limb-threatening than impaired circulation. Nutrition supports healing over time, but it does not address the highest-acuity risk after casting.

Question 34

A 27-year-old man arrives at the clinic with priapism. The nurse is aware that the client is at risk for which condition?

Accepted Answer

Answer reason: Ongoing ischemia can cause necrosis of penile tissue and ultimately gangrene if not rapidly treated, making this the key feared complication. This is why priapism is managed as a urologic emergency with urgent decompression and correction of the cause. Hydronephrosis and testicular atrophy are not direct expected consequences of cavernosal ischemia, and DIC is not a typical complication of priapism itself.

Question 35

A client with extensive burns has a new donor site. What is the most important intervention by the nurse?

Accepted Answer

Answer reason: New donor sites are essentially superficial partial-thickness wounds, and the top priority is preventing bleeding, shear/trauma, and graft-site disruption that can lead to infection and delayed healing. Pressure or friction can dislodge the fragile clot and newly forming epithelium, increasing pain and causing re-bleeding. Positioning and handling that offloads the site reduces these complications while the dressing protocol (open-to-air vs covered) varies by provider order and product used. Making the site dependent would worsen edema and bleeding risk, and “ventilation” is not universally appropriate because many donor sites are managed with occlusive or semi-occlusive dressings.

Question 36

Laboratory analysis reveals that the client passed a calcium oxalate stone. To prevent the formation of future stones, the nurse should instruct the client to avoid consuming which food?

Accepted Answer

Answer reason: Cocoa and chocolate are classic high-oxalate items and can increase oxalate load, raising the risk of recurrence. In contrast, cheese is primarily a calcium source and is not the typical food to avoid; overly restricting calcium can paradoxically increase intestinal oxalate absorption. Lettuce is low in oxalate, and while some legumes contain oxalate, chocolate is the most clearly high-oxalate option here.

Question 37

During the assessment of a client who had an abdominal aortic repair, the nurse notes a hematoma in the perineal area. The nurse interprets this as?

Accepted Answer

Answer reason: Perineal ecchymosis/hematoma after abdominal aortic repair suggests blood tracking into dependent tissues, which is a classic sign of retroperitoneal bleeding. A leak or rupture at the graft/anastomosis can bleed into the retroperitoneal space and may not produce obvious external hemorrhage, making cutaneous bruising an important warning sign. This represents a life-threatening postoperative complication requiring urgent evaluation and hemodynamic monitoring. A stage 1 pressure injury is non-blanchable erythema without a hematoma, and a hernia would present as a bulge rather than bruising.

Question 38

A nurse is preparing a client for cardiac catheterization. What is the priority assessment for the nurse to obtain?

Accepted Answer

Answer reason: A history of iodine/contrast or shellfish allergy signals increased risk for hypersensitivity reactions, including bronchospasm and anaphylaxis, which require advance planning (premedication, alternative contrast, emergency readiness). Baseline vitals and rhythm are important but are not as time-critical as identifying a contraindication/risk that could cause rapid clinical deterioration during dye administration. Weight/height may inform dosing or renal-risk planning, but it does not supersede identification of a potentially life-threatening allergy.

Question 39

The nurse is providing discharge instructions for a client who has undergone a gastric resection. The nurse is aware that the client is at risk for?

Accepted Answer

Answer reason: Gastric resection can reduce normal gastric reservoir function and pyloric control, allowing rapid emptying of hyperosmolar stomach contents into the small intestine. This fluid shift and exaggerated gut hormone response can cause postprandial cramping, diarrhea, tachycardia, diaphoresis, and later reactive hypoglycemia, making it a key discharge-teaching risk. The other options are not characteristic, high-yield complications specifically associated with gastric resection compared with the well-recognized dumping physiology. Discharge instructions typically focus on small frequent meals, limiting simple carbohydrates, separating fluids from meals, and higher protein/fat to slow transit.

Question 40

A client has just had surgery for colon cancer. The nurse is aware that the client is most at risk for developing which condition?

Accepted Answer

Answer reason: This complication is immediately life-threatening and is a key priority risk the nurse must monitor for (e.g., increasing abdominal pain/distention, fever, tachycardia, rigid abdomen). Diverticulosis is a chronic condition related to colonic wall outpouchings and is not a direct postoperative risk. Bowel obstruction can occur from adhesions, but it is more typically a later complication rather than the most immediate major risk right after colon cancer surgery.

Question 41

The nurse is assessing a postoperative client who is recovering from a partial gastrectomy. The nurse is aware that the client is at risk for developing?

Accepted Answer

Answer reason: Partial gastrectomy can impair intrinsic factor production and reduce gastric acid, which decreases absorption of vitamin B12 and iron needed for erythropoiesis. Over time this increases risk for nutritional anemias (iron deficiency and/or megaloblastic anemia from B12 deficiency), making reduced hemoglobin/hematocrit a key complication to monitor. The other choices are not typical direct consequences of decreased gastric capacity/secretions after gastrectomy; for example, polycythemia reflects increased RBC mass rather than malabsorption. Nursing surveillance focuses on fatigue, pallor, and trending CBC indices with appropriate supplementation as prescribed.

Question 42

A client with multiple myeloma has developed hypercalcemia. The nurse is aware that the client is at risk for what secondary complication?

Accepted Answer

Answer reason: Multiple myeloma already predisposes the client to renal damage from light-chain (Bence Jones) proteinuria, so elevated calcium further amplifies the risk of renal impairment. Muscle spasms are more consistent with hypocalcemia-related neuromuscular irritability (tetany), not hypercalcemia. Although dysrhythmias can occur, the more classic and high-yield secondary complication of sustained hypercalcemia in this setting is worsening renal function.

Question 43

What is the most appropriate nursing intervention to promote healing of a laceration?

Accepted Answer

Answer reason: Healing is promoted by minimizing edema and improving venous/lymphatic return, which reduces tissue pressure and supports local perfusion at the wound edges. Elevation above heart level decreases swelling and pain, helping approximate tissues and facilitating the normal inflammatory and proliferative phases of wound repair. In contrast, applying ice with pressure is most useful for acute bleeding or swelling control immediately after injury, but it is not the primary ongoing intervention specifically aimed at promoting healing. Monitoring blood pressure does not directly optimize local wound conditions for tissue repair unless there is a broader hemodynamic concern.

Question 44

The nurse is caring for a client with compartment syndrome. The nurse anticipates that the client may require which measure?

Accepted Answer

Answer reason: Definitive management is urgent decompression to restore circulation and prevent permanent damage, which is achieved by surgical opening of the fascia. Casting would worsen pressure and ischemia, and observation is unsafe because progression can be rapid and irreversible. Amputation is a last-resort outcome if ischemia progresses to nonviable tissue, but the anticipated necessary measure to prevent that is decompression.

Question 45

A nurse is caring for a client with a femoral shaft fracture. Which of the following assessment findings is serious and warrants immediate intervention by nurse?

Accepted Answer

Answer reason: Active or suspected bleeding requires immediate nursing intervention (rapid assessment, vital signs, neurovascular checks, maintaining immobilization, and urgent provider/rapid response notification as indicated). While decreased urine output can be a later indicator of poor perfusion, it is less specific and typically follows significant volume loss. Pain is expected with fractures and constipation is non-urgent, whereas uncontrolled bleeding is a time-critical complication.

Question 46

Which of the following clinical manifestations would lead the nurse to suspect a fat embolus in a client who has a left femur fracture?

Accepted Answer

Answer reason: New-onset shortness of breath is therefore a key clinical trigger for suspicion, often preceding or accompanying tachypnea and low oxygen saturation. Neurologic changes (e.g., confusion) and petechiae can occur, but isolated headache is less specific than respiratory compromise for this diagnosis. Local symptoms like leg numbness or thigh muscle spasm are more consistent with neurovascular injury or pain/spasm from the fracture itself rather than systemic embolization.

Question 47

What discharge information should be given to a client with a cast?

Accepted Answer

Answer reason: A key discharge teaching priority with casts is early recognition of complications such as infection and skin breakdown. Fever and a foul odor can indicate an underlying wound infection or tissue necrosis beneath the cast, requiring prompt evaluation and possible cast removal or treatment. Normal itching is common from healing skin and dryness and does not by itself signal infection, so it should not be framed as an infection indicator. Putting powder or objects under the cast increases moisture/skin irritation and infection risk, and keeping the extremity dependent worsens edema and can contribute to neurovascular compromise.

Question 48

When caring for a client with quadriplegia, which nursing intervention takes priority?

Accepted Answer

Answer reason: Quadriplegia increases risk for hypoventilation, retained secretions, and mucus plugging, making prevention of atelectasis a top complication to address early with turning, deep-breathing/coughing assistance, and pulmonary hygiene. Skin care and hydration are important but are generally longer-horizon risks compared with immediate ventilation problems. Promoting independence with adaptive devices improves function but does not supersede urgent physiologic stability.

Question 49

Which client would be considered to be at the highest risk for respiratory failure?

Accepted Answer

Answer reason: This disorder causes acute, ascending neuromuscular weakness that can involve the bulbar muscles and respiratory musculature, so forced vital capacity can fall quickly and require ventilatory support. Early deterioration may be subtle, making close monitoring for declining respiratory function and aspiration risk essential. In contrast, the other conditions listed do not typically cause acute neuromuscular ventilatory failure as a primary complication.

Question 50

The client is receiving positive end-expiratory pressure (PEEP) therapy. The nurse anticipates that the client will exhibit which of the following?

Accepted Answer

Answer reason: Lower preload reduces stroke volume and can therefore reduce overall cardiac output, especially at higher PEEP levels or in hypovolemia. This is a classic hemodynamic complication nurses monitor for during mechanical ventilation with PEEP. A common associated finding can be hypotension, making the “increased blood pressure” option inconsistent with the expected physiologic effect.

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