Question 1

The nurse is aware that a client who had a repair of total anomalous pulmonary venous return is at risk for which of the following?

Accepted Answer

Answer reason: Persistent or recurrent pulmonary hypertension can rapidly impair right ventricular function and reduce pulmonary blood flow, making it a high-priority complication to monitor for. This risk is closely tied to the underlying pre-repair physiology (excess pulmonary blood flow/pressure) and to possible postoperative pulmonary venous stenosis. Hypotension and ventricular arrhythmias can occur after cardiac surgery, but they are less specifically associated with this particular defect and its repair than pulmonary hypertension.

Question 2

The most appropriate information for the nurse to give the parents of a child with aortic stenosis would be?

Accepted Answer

Answer reason: Aortic stenosis creates a fixed left-ventricular outflow obstruction, so the child cannot reliably increase cardiac output during exertion and is at risk for syncope, chest pain, and sudden deterioration with strenuous activity. Teaching families to limit vigorous exercise reduces myocardial oxygen demand and avoids dangerous drops in perfusion during exertion. Routine dental care should not be avoided; instead, infective endocarditis prophylaxis is considered only for specific high-risk cardiac lesions/procedures, so blanket avoidance is incorrect. Digoxin and fluid restriction are not universal instructions for isolated aortic stenosis and are only used when heart failure or specific indications exist.

Question 3

A child who received a heart transplant has been taking prednisone. The nurse is most concerned when the child experiences which of the following?

Accepted Answer

Answer reason: A very high fever is therefore a red-flag finding that may signal sepsis or opportunistic infection requiring urgent evaluation and treatment. While steroids can contribute to delayed wound healing, this is typically a chronic adverse effect rather than an immediate life-threatening complication. Weight loss and anorexia are nonspecific and less concerning than extreme fever in an immunosuppressed child.

Question 4

A nurse is caring for a child with Kawasaki disease. Which symptom should concern the nurse the most?

Accepted Answer

Answer reason: Significant abdominal pain with vomiting is concerning because it can indicate more severe systemic involvement (vasculitis affecting GI perfusion/mesenteric vessels), dehydration, and potential hemodynamic compromise that requires prompt evaluation. By comparison, mild diarrhea and joint pain are relatively common, non-specific inflammatory findings that are typically not immediately life-threatening. An elevated ESR is an expected inflammatory marker in Kawasaki disease and, by itself, does not signal acute deterioration.

Question 5

The nurse is aware that an infant who had surgical repair of a tracheoesophageal fistula is most at risk for which of the following?

Accepted Answer

Answer reason: After tracheoesophageal fistula repair, airway edema and reduced lung expansion further increase the likelihood of alveolar collapse. This makes respiratory complications like diminished breath sounds and hypoxia from atelectasis the most immediate and common risk to monitor for. Choking with feeds can occur if there is stricture or recurrent fistula, but feeding is typically delayed and advanced cautiously, making it less immediate than pulmonary collapse in the early postoperative period. Infection is a general surgical risk, but it is not as specifically high-yield or as immediate as postoperative pulmonary atelectasis in this population.

Question 6

The nurse is aware that a child receiving chelation therapy for the treatment of lead poisoning is at risk for which condition?

Accepted Answer

Answer reason: This can lower ionized calcium levels, so the child must be monitored for neuromuscular irritability (perioral tingling, tetany, cramps) and dysrhythmias. The glucose options are not typical direct complications of chelation therapy and would prompt looking for other causes rather than being expected adverse effects. Ongoing assessment of serum electrolytes and clinical signs is key to preventing progression to seizures or cardiac instability.

Question 7

The nurse is providing preoperative care for a child diagnosed with appendicitis. What is the most appropriate intervention?

Accepted Answer

Answer reason: Preoperative management of suspected appendicitis prioritizes minimizing the risk of perforation and peritonitis by limiting activity and avoiding interventions that increase intra-abdominal pressure. Bed rest supports comfort and reduces agitation and movement that can worsen pain or contribute to rupture in an inflamed appendix. Clear fluids are typically avoided because the child is usually kept NPO in anticipation of surgery and possible anesthesia. Heat and enemas are contraindicated because they can increase local blood flow or stimulate bowel activity, both of which may precipitate rupture.

Question 8

A nurse recognizes that the parent of a child with developmental hip dysplasia needs more teaching when the parent places the child in a position that encourages?

Accepted Answer

Answer reason: In developmental dysplasia of the hip, positioning that maintains the femoral head well-seated in the acetabulum is achieved with hip flexion and abduction, which promotes joint stability and development. Positions that force the legs straight can counter the therapeutic posture and increase the risk of poor alignment or redislocation when a harness/splint is used. Therefore, placing the child in a position that encourages straightening the knees indicates misunderstanding of safe positioning principles. Teaching should reinforce avoiding straight-leg positioning and supporting flexion/abduction as prescribed.

Question 9

The nurse is monitoring a child with a diagnosis of pertussis. The nurse is most concerned when the child develops which of the following?

Accepted Answer

Answer reason: A sudden high fever suggests a new or worsening process such as secondary bacterial pneumonia, sepsis, or another serious complication that requires prompt evaluation and treatment. This finding represents a change from the expected clinical course and signals higher risk for rapid deterioration. In contrast, whooping cough is a classic, expected manifestation of pertussis rather than an alarming new development.

Question 10

Which of the following responses from a client should the nurse address first?

Accepted Answer

Answer reason: ” Orthostatic dizziness suggests hemodynamic instability from dehydration, malnutrition, bradycardia, or electrolyte disturbances, which can quickly progress to syncope and injury. In clients with eating disorders, this symptom can indicate immediate physiologic compromise requiring prompt assessment of vital signs (including orthostatics), hydration status, and cardiac risk. The other statements reflect important concerns (cognitive distortions, dental pain from vomiting, and weakness from malnutrition/electrolyte issues), but they are less immediately threatening than possible orthostatic hypotension and impending collapse. Prioritizing potential acute compromise follows ABCs/safety and complication prevention principles.

Question 11

A client is receiving I.V. magnesium sulfate for severe preeclampsia. It is most important for the nurse to assess the client for which of the following?

Accepted Answer

Answer reason: Monitoring urine output is a key early safety assessment because oliguria indicates reduced clearance and rising serum magnesium levels. Magnesium toxicity progresses to loss of deep tendon reflexes and respiratory depression, so catching decreased output helps prevent these life-threatening complications before they appear. Hyperreflexia is more consistent with worsening preeclampsia rather than magnesium excess, and an increased respiratory rate is not the expected early sign of toxicity.

Question 12

To detect pulmonary embolus in a client in the immediate postpartum period, a nurse should be alert to which symptoms?

Accepted Answer

Answer reason: This typically presents abruptly with shortness of breath, pleuritic chest pain, tachypnea, and possible hypoxemia/anxiety because ventilation-perfusion mismatch occurs immediately. Chills and fever are more consistent with infection such as endometritis rather than an embolic event. Bradycardia with hypertension or confusion with bradypnea are not classic early PE patterns and would more strongly suggest other neurologic or medication-related etiologies.

Question 13

A client’s sodium is 122 mEq/L. Which action is a priority nursing intervention?

Accepted Answer

Answer reason: Severe hyponatremia increases the risk of cerebral edema, which can rapidly lead to neurologic deterioration and seizures. A sodium of 122 mEq/L is low enough that immediate safety measures to prevent injury from a possible seizure are the highest priority nursing action. Increasing fluids would typically worsen dilutional hyponatremia and can further lower sodium, escalating neurologic risk. Frequent vital signs and cardiac monitoring may be appropriate depending on etiology and comorbidities, but they do not address the most imminent life-threatening complication in this lab finding.

Question 14

The nurse cares for a client who returns from a cystoscopy. The nurse knows that which assessment finding is within normal limits for this client?

Accepted Answer

Answer reason: After cystoscopy, mild hematuria is an expected finding due to transient mucosal irritation from instrumentation. Small amounts of pink or blood-tinged urine and mild dysuria should improve with hydration and time. In contrast, decreased urine output may indicate obstruction from clots or urinary retention and requires prompt evaluation. Severe pelvic/abdominal pain or fever are not expected and can signal perforation or infection, making them abnormal post-procedure findings.

Question 15

A client is hospitalized for 5 days with mononucleosis. Which assessment finding indicates a possibly serious consequence?

Accepted Answer

Answer reason: EBV can cause hepatic inflammation and cholestasis, and a change in urine color suggests clinically significant liver involvement rather than an expected, self-limited symptom. In contrast, low-grade fever and cervical lymphadenopathy are common expected findings in mononucleosis, and vomiting is nonspecific unless accompanied by other warning signs. This finding warrants prompt evaluation of liver function and assessment for jaundice and worsening systemic illness.

Question 16

Which nursing action is correct for performing tracheal suctioning?

Accepted Answer

Answer reason: Tracheal suctioning can rapidly cause hypoxemia, dysrhythmias, and mucosal trauma due to airway occlusion and vagal stimulation. Limiting each suction pass to about 10–15 seconds minimizes oxygen desaturation while still allowing effective secretion removal. Suction is applied only while withdrawing the catheter (not during insertion) to reduce mucosal injury and hypoxia. Reusing/"resterilizing" a catheter in alcohol is not an acceptable infection-control practice, and suctioning should be based on patient assessment (e.g., visible/auscultated secretions, increased peak pressures) rather than fixed 15-minute intervals.

Question 17

The client is diagnosed with acute pericarditis. During the shift assessment, the nurse notes muffled heart sounds. Which intervention should the nurse implement?

Accepted Answer

Answer reason: Muffled heart sounds in a client with acute pericarditis suggest developing pericardial effusion with risk of cardiac tamponade, a rapidly life-threatening complication. This finding warrants immediate provider notification for urgent evaluation (e.g., focused assessment for hypotension, JVD, pulsus paradoxus) and likely diagnostic testing such as echocardiography and potential intervention. Delaying care by simply monitoring or rechecking later risks progression to obstructive shock. Telemetry may be helpful but does not address the immediate need to evaluate and treat possible tamponade.

Question 18

The nurse is caring for a client who is diagnosed with Cushing’s disease. It is most important for the nurse to assess the client for which condition?

Accepted Answer

Answer reason: Nursing assessment should therefore emphasize blood glucose monitoring and symptoms of hyperglycemia because uncontrolled elevations increase infection risk and impair wound healing. Compared with disorders of ADH (DI/SIADH), cortisol excess does not primarily present with profound free-water imbalance as the highest-likelihood complication. Addison’s disease reflects cortisol deficiency, which is the opposite endocrine state and not the expected comorbidity from Cushing’s.

Question 19

The nurse is planning care for a client who is diagnosed with Cushing’s syndrome. Which of the following nursing diagnoses would be appropriate for this client?

Accepted Answer

Answer reason: Clients with Cushing’s also commonly have hyperglycemia and fragile skin, which further slows healing and raises infection risk from minor breaks or invasive lines. Fluid volume problems in Cushing’s more typically involve sodium and water retention with edema and hypertension rather than deficit, making that diagnosis less fitting. Impaired gas exchange and acute pain are not characteristic primary problems of Cushing’s unless another acute condition is present.

Question 20

Which nursing intervention is appropriate for a client who had breast reconstruction surgery?

Accepted Answer

Answer reason: Post–breast reconstruction care prioritizes protecting the surgical site and preventing complications such as hematoma/seroma, bleeding, and disruption of the flap/implant pocket. Even, gentle support and pressure with the ordered dressing/binder helps minimize dead space and shear forces that can compromise perfusion and wound integrity. Positioning the client on the operative side increases pressure and can impair circulation to the reconstructed area. Aggressive arm elevation early can place tension on incisions and drains; range-of-motion is typically progressed gradually per surgeon protocol.

Question 21

What is the most important information for the nurse to give a client to decrease the risk of toxic shock syndrome?

Accepted Answer

Answer reason: Toxic shock syndrome risk increases with prolonged tampon use because extended retention can promote Staphylococcus aureus growth and toxin production, especially with higher-absorbency products. Avoiding tampon use overnight reduces the duration a foreign body remains in the vagina, lowering the chance of bacterial proliferation and toxin exposure. While douching and tight/non-breathable underwear can contribute to irritation or altered flora, they are not the key modifiable factor most directly linked to TSS. Avoiding intercourse during menses is not a primary, evidence-based TSS prevention strategy compared with limiting tampon duration and using pads when sleep may extend wear time.

Question 22

Which discharge instruction should be given to a client after a prostatectomy?

Accepted Answer

Answer reason: After prostatectomy, increasing intra-abdominal pressure can stress the surgical site and provoke bleeding, pain, or disruption of healing, so preventing constipation and avoiding Valsalva is a key discharge priority. Teaching includes using stool softeners, high-fiber diet, and adequate fluids (as permitted) to maintain soft stools. Passing small amounts of blood-tinged urine can occur early, so the most universally correct instruction is to avoid straining rather than treating any clot as an automatic emergency. Warm tub soaking and a fixed timeline to resume usual activities can be unsafe because baths may increase infection risk early and activity restrictions vary by procedure and recovery.

Question 23

A client is receiving a radiation implant for the treatment of bladder cancer. Which intervention is appropriate?

Accepted Answer

Answer reason: Radiation to the bladder can inflame and irritate the bladder mucosa, placing the client at risk for radiation cystitis. Nursing care should focus on early detection of complications such as dysuria, frequency/urgency, suprapubic pain, hematuria, and fever so treatment can be initiated promptly. Restricting fluids is generally inappropriate because adequate hydration helps dilute urine and reduce irritation unless specifically contraindicated. Room type and routine urine flushing are not the key priority interventions for a sealed radiation implant compared with monitoring for expected urinary tract complications.

Question 24

A client with acute renal failure has a serum potassium level of 7.0 mEq/L. The nurse’s priority for this client is to assess which of the following?

Accepted Answer

Answer reason: A potassium level of 7.0 mEq/L warrants urgent assessment for electrical conduction changes such as peaked T waves, PR prolongation, QRS widening, and sine-wave patterns. ECG evaluation directly identifies impending instability and guides rapid interventions (e.g., calcium, insulin/dextrose, dialysis) before deterioration occurs. Other assessments like urine specific gravity, mental status, and blood pressure are important in renal failure but are less time-critical than detecting hyperkalemia-related cardiotoxicity.

Question 25

Which client is at greatest risk for developing acute renal failure?

Accepted Answer

Answer reason: Diabetes is a major risk factor because diabetic nephropathy and microvascular disease reduce the kidneys’ ability to tolerate nephrotoxic insults and hemodynamic shifts. This client also faces additional renal stress from potential peri-procedure hypotension and atheroembolism, both of which can further reduce renal perfusion. In comparison, routine appendectomy in a healthy teen and influenza in someone already on dialysis are less likely to newly precipitate acute renal failure as the primary complication being tested.

Question 26

The client, returning from a coronary catheterization in which the femoral artery approach was used, sneezes. Which should be the nurse’s priority intervention?

Accepted Answer

Answer reason: The most immediate, high-risk complication to identify is active bleeding, because it can rapidly progress to significant blood loss and hemodynamic instability. Direct inspection/palpation of the groin site allows the nurse to detect oozing, frank hemorrhage, or expanding hematoma and intervene promptly with pressure and notification of the provider. Vital signs and distal pulses are important follow-up assessments, but they may change after bleeding has already occurred, making access-site assessment the priority.

Question 27

The client is discovered to have a popliteal aneurysm. Because of the aneurysm, the nurse should closely monitor the client for which associated problem?

Accepted Answer

Answer reason: This makes acute or progressive limb ischemia a key complication requiring close neurovascular monitoring (pain, pallor, pulselessness, paresthesia, paralysis, poikilothermia). A pulmonary embolism is primarily a venous thromboembolism complication rather than an expected direct consequence of an arterial popliteal aneurysm. Thoracic outlet syndrome and Raynaud’s phenomenon are unrelated upper-extremity/vasospastic disorders and are not typical complications of a popliteal aneurysm.

Question 28

The client with Crohn’s disease has undergone a barium enema that showed strictures in the ileum. Based on this finding, the nurse should monitor the client closely for signs of which complication?

Accepted Answer

Answer reason: The priority complication to monitor is obstruction, which presents with crampy abdominal pain, abdominal distention, nausea/vomiting, and decreased passage of stool or flatus. Peritonitis is more associated with perforation and would require additional findings such as rigid abdomen and rebound tenderness rather than simply a stricture. Malabsorption can occur with ileal disease, but strictures specifically signal luminal narrowing and impending blockage as the most direct complication to watch for.

Question 29

The nurse is assessing the client receiving peritoneal dialysis. Which finding suggests that the client may be developing peritonitis?

Accepted Answer

Answer reason: Cloudy effluent is an early, classic assessment finding that should trigger rapid follow-up (e.g., send effluent for cell count/culture) and prompt provider notification to prevent sepsis and catheter failure. Abdominal numbness is not a typical infection indicator, while radiating sternal pain is more consistent with cardiac or esophageal etiologies than intraperitoneal infection. A decreased WBC count would not be expected with an acute bacterial peritonitis, where leukocytosis is more common.

Question 30

After undergoing a cardiac catheterization, a client has a large puddle of blood under his buttocks. The most important intervention by the nurse is?

Accepted Answer

Answer reason: A large amount of blood after cardiac catheterization indicates possible femoral access-site hemorrhage, which can rapidly lead to hypovolemia and shock. The immediate priority is to identify the bleeding source and assess the puncture site so direct pressure and appropriate escalation can be initiated without delay. Vital signs are important but are a secondary assessment after confirming and controlling suspected bleeding. Asking the client to lift up delays assessment and may worsen bleeding by flexing the hip and disrupting hemostasis.

Question 31

Which nursing intervention should be the priority when caring for a client with appendicitis?

Accepted Answer

Answer reason: Priority nursing care focuses on early detection of deterioration (e.g., increasing/worsening abdominal pain, rebound tenderness, rigid abdomen, fever, tachycardia, hypotension) to prevent sepsis and shock. Pain assessment is important but does not identify imminent rupture and systemic compromise as directly as monitoring for peritoneal signs. Encouraging oral fluids is inappropriate because clients are typically kept NPO in anticipation of surgery and to reduce aspiration risk.

Question 32

The nurse is prioritizing care for a client 2 days after surgery for a stoma creation that resulted from ulcerative colitis. What is the most important issue for the nurse to address?

Accepted Answer

Answer reason: Stoma effluent and frequent pouch changes can rapidly cause peristomal skin breakdown, which then leads to poor pouch adhesion, leakage, pain, and increased risk for local infection. Early nursing care focuses on protecting the peristomal area (proper wafer fit, barrier products, and assessment for irritation) to maintain a functional seal and healing. Psychosocial issues such as body image and sexual concerns are important but are typically addressed after physiologic stabilization and complication prevention. Teaching general ostomy management is also essential, but it depends on intact skin and a secure appliance to be effective.

Question 33

The nurse is aware that the most important intervention when caring for a client with esophageal varices is which of the following?

Accepted Answer

Answer reason: Nursing care centers on close surveillance for hematemesis, melena, sudden hypotension, tachycardia, falling hemoglobin/hematocrit, and changes in level of consciousness so emergency interventions can be initiated immediately. While controlling hypertension may reduce bleeding risk in some settings, portal hypertension (not systemic blood pressure) is the primary driver of variceal rupture, so it is not the most critical nursing focus. Nutrition and teaching are important for long-term management but do not supersede immediate life-threatening complication monitoring.

Question 34

A client with a diagnosed liver disorder is scheduled to have an invasive procedure. The nurse will monitor which test result to ensure the safety of the client?

Accepted Answer

Answer reason: Monitoring PT/INR, aPTT, and platelet-related coagulation parameters best identifies unsafe coagulopathy that may require correction (e.g., vitamin K, plasma, platelets) before proceeding. Liver enzyme levels reflect hepatocellular injury but do not directly predict procedural hemorrhage risk. WBC count and general serum chemistries may be relevant for infection or metabolic status, but they are less critical than coagulation status for immediate procedural safety.

Question 35

Which intervention should be the priority of nursing management for a client hospitalized for acute cholecystitis?

Accepted Answer

Answer reason: Priority nursing management emphasizes ongoing focused assessment (vital signs, escalating RUQ pain/guarding, fever, hypotension, jaundice, worsening labs) to detect these complications promptly and trigger timely interventions. Antibiotics may be ordered and important, but they are not the first priority if the patient is developing an acute complication that requires immediate escalation. Preparation for lithotripsy is not standard acute management, and surgery preparation is contingent on stabilizing the patient and monitoring for emergent complications.

Question 36

A client has a percutaneous endoscopic gastrostomy tube inserted for continuous tube feedings. What is the best position for the nurse to place the client in before starting the feeding?

Accepted Answer

Answer reason: Semi-Fowler’s (about 30–45 degrees) is the standard minimum elevation recommended before and during continuous tube feeding, and typically for a period afterward, to prevent aspiration. Supine positioning increases aspiration risk and is unsafe for initiating feeds. High Fowler’s may be acceptable but is not necessary for all patients and can be less tolerated; the key best-practice minimum is Semi-Fowler’s.

Question 37

The nurse is reviewing client’s charts. Select the client who would be most at risk for developing anemia?

Accepted Answer

Answer reason: Nursing home residents are also more likely to have polypharmacy and comorbid renal disease, both of which can impair erythropoiesis. Compared with younger adults, they have less physiologic reserve, so mild deficits and chronic conditions more readily translate into clinically significant low hemoglobin. A toddler can develop iron-deficiency anemia, but the overall “most at risk” group among these choices is the institutionalized elderly due to multiple converging risk factors.

Question 38

While assessing a client with disseminated intravascular coagulation (DIC), the nurse suspects the client has developed internal bleeding. The nurse should assess the client for?

Accepted Answer

Answer reason: Internal bleeding is suggested by occult fluid/blood accumulation and signs of hypovolemia rather than superficial skin findings. In DIC, consumption of platelets and clotting factors can lead to bleeding into body cavities, including the abdomen, where hemorrhage may present as progressive distention and increased girth. Hypertension and bradycardia are not typical early indicators of hemorrhage, as bleeding more commonly causes hypotension and tachycardia. Petechiae reflect capillary bleeding on the skin/mucosa and are not a key assessment finding for internal abdominal hemorrhage.

Question 39

Which of the following interventions would help prevent deep vein thrombosis (DVT) after hip surgery?

Accepted Answer

Answer reason: Pharmacologic prophylaxis with low-dose anticoagulation reduces clot formation, and intermittent pneumatic compression promotes venous return to counter stasis. Using both methods together provides stronger DVT prevention than either alone in many postoperative protocols. Bed rest worsens venous stasis, while an egg crate mattress targets pressure-injury prevention and pulmonary care targets atelectasis/pneumonia rather than DVT risk.

Question 40

Which instruction given to a client after cataract surgery is incorrect?

Accepted Answer

Answer reason: Post–cataract surgery teaching focuses on preventing sudden increases in intraocular pressure by avoiding activities that raise venous/ocular pressure such as bending, heavy lifting, coughing, or straining. Dietary sodium restriction is not a standard or meaningful intervention for controlling acute intraocular pressure in this postoperative context, making this instruction inaccurate. In contrast, avoiding bending/straining is appropriate because it can precipitate wound dehiscence or bleeding. Avoiding eye makeup early on is also appropriate to reduce contamination and infection risk while the incision heals.

Question 41

When assessing a client with herniated nucleus pulposus of L4–L5, the nurse should expect to find which sign or symptom of spinal cord compression?

Accepted Answer

Answer reason: At the L4–L5 level, a large herniation can compress cauda equina nerve roots, producing urinary retention or overflow incontinence as a key red-flag finding. In contrast, localized low back pain or radicular pain into the buttocks reflects nerve root irritation (sciatica) rather than cord-level compression. Kernig’s sign indicates meningeal irritation (e.g., meningitis/subarachnoid hemorrhage) and is not expected with a lumbar disc herniation.

Question 42

The nurse is preparing a plan of care for a postoperative client. What is the most appropriate nursing intervention to prevent the development of atelectasis?

Accepted Answer

Answer reason: Incentive spirometry promotes sustained maximal inspiration, helping re-expand alveoli, improve ventilation, and mobilize secretions, making it a first-line preventive nursing intervention. Chest physiotherapy is more commonly used for secretion clearance when retention is present rather than routine prevention in uncomplicated postoperative clients. Mechanical ventilation is invasive and reserved for respiratory failure, not prevention, and “reducing oxygen requirements” does not address the underlying problem of alveolar collapse.

Question 43

The nurse is caring for a client who recently had a central venous catheter inserted and now appears short of breath and anxious. The nurse anticipates that the physician will order a?

Accepted Answer

Answer reason: Acute dyspnea and anxiety shortly after central venous catheter insertion raises concern for an iatrogenic complication, especially pneumothorax from pleural puncture. The fastest, standard confirmatory test to evaluate catheter-related pneumothorax and verify line placement is an immediate post-procedure chest radiograph. An ECG would be more targeted to dysrhythmias from catheter tip irritation but does not assess lung expansion. Sedation would be unsafe because it can depress respirations and delay recognition and treatment of a potentially life-threatening complication.

Question 44

A client alerts the nurse that his chest tube has accidentally been removed. What is the most appropriate action by the nurse?

Accepted Answer

Answer reason: A dislodged chest tube creates an open pathway for air to enter the pleural space, which can rapidly cause or worsen a pneumothorax and precipitate respiratory compromise. The immediate nursing priority is to seal the insertion site to prevent additional air entry while summoning urgent provider assistance and monitoring for signs of tension physiology. An occlusive (typically petroleum gauze) dressing is the standard emergency measure to restore a closed system until definitive reinsertion can be performed by an authorized clinician. Repositioning alone does not address ongoing air leak, and attempting to reinsert the tube is outside nursing scope and risks tissue injury and infection.

Question 45

When children are more physically active, which change in the management of the child with diabetes should the nurse expect?

Accepted Answer

Answer reason: To prevent exercise-induced hypoglycemia, management typically includes adding carbohydrates (extra snack/meal) and/or adjusting insulin dosing around activity. Increasing intake is the most expected nursing-focused change because it is a practical, immediate strategy families can implement during sports and play. A common misconception is that activity raises glucose; in most children on insulin, the immediate risk is hypoglycemia rather than hyperglycemia.

Question 46

The mother of a neonate born with a cleft lip and palate is preparing to feed the baby for the first time. The most important information for the nurse to give the mother is?

Accepted Answer

Answer reason: Feeding a newborn with cleft lip/palate carries a high aspiration risk because the infant cannot generate an effective oral seal and milk can reflux into the nasopharynx. Upright positioning uses gravity to reduce nasal regurgitation and helps protect the airway during swallowing, making it the top immediate safety intervention for the first feeding. Burping is helpful due to increased air swallowing, but it does not address the primary life-threatening complication. A normal nursery nipple is typically ineffective; many infants require specialized nipples, so recommending a standard nipple is unsafe/incomplete.

Question 47

A client is admitted with a history of tracheoesophageal fistula and esophageal atresia repair. The nurse is aware that the client is at risk for which of the following?

Accepted Answer

Answer reason: This complication most directly explains later symptoms such as progressive dysphagia, regurgitation, poor weight gain, or recurrent respiratory issues from aspiration of retained feeds. While gastroesophageal reflux is also common after this repair, the question asks for the key risk to anticipate as a structural complication of healing. Early recognition allows prompt evaluation (e.g., contrast study/endoscopy) and management such as dilation to prevent feeding and aspiration complications.

Question 48

After surgical repair of pyloric stenosis, the nurse should expect an infant’s normal feeding regimen to resume after what time frame?

Accepted Answer

Answer reason: Infants are typically started on small, clear or electrolyte feeds a few hours after surgery and then progressed in volume and concentration. A full return to the preoperative “normal” feeding pattern commonly takes about 24–48 hours depending on emesis and hydration status. The shorter time frame is more consistent with initiating feeds rather than resuming a normal regimen, while 1 week is unnecessarily prolonged for an uncomplicated recovery.

Question 49

The nurse is caring for a child in the recovery phase following an ingestion of drain cleaner. The nurse is aware that the child is at risk for which of the following?

Accepted Answer

Answer reason: During recovery, healing occurs with granulation tissue and fibrosis, which can progressively narrow the lumen and lead to dysphagia and food impaction. This is a classic delayed complication days to weeks after the burn, so monitoring for swallowing difficulty and ensuring appropriate follow-up (e.g., evaluation for stricture) is key. Airway narrowing is less typical as the primary late complication unless there was significant inhalational injury, and varices/diverticula are not expected sequelae of caustic burns.

Question 50

A child with Reye’s syndrome is in stage I of the illness. Which measure can be taken to prevent further progression of the illness?

Accepted Answer

Answer reason: Prompt administration of concentrated dextrose helps maintain serum glucose and reduces secondary brain injury from energy failure. Stage I management prioritizes preventing metabolic deterioration; advanced airway support and neuromuscular blockade are typically reserved for later stages with declining consciousness or respiratory compromise. Invasive monitoring may be needed if the child deteriorates, but it does not directly address the early, preventable metabolic driver of progression.

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