Question 1

Nursing care for a client in traction may include which intervention?

Accepted Answer

Answer reason: Routine assessment each shift allows early detection of redness, drainage, warmth, increasing pain, or loosening that can signal pin-site infection or impaired fixation. In contrast, knots should never catch on the pulley because that disrupts the line of pull and reduces traction effectiveness. Weights are not added/removed per client request, and ROM is targeted to unaffected joints while maintaining prescribed alignment rather than indiscriminately moving all joints every shift.

Question 2

Which diagnostic test should be included in the care plan for children with an increased risk of sudden infant death syndrome (SIDS)?

Accepted Answer

Answer reason: Home apnea monitoring is used to detect apnea and bradycardia and trigger an alarm so caregivers can intervene promptly, reducing the risk of an unrecognized event. Routine pulmonary function tests are not practical or clinically indicated for infants and do not target the acute risk mechanism. Spot or continuous pulse oximetry during sleep is not the standard diagnostic strategy for SIDS risk because oxygen desaturation can occur late and monitoring does not reliably prevent events; routine chest X-ray screening has no preventive value.

Question 3

The nurse is reviewing the plan of care for the client with sickle cell disease who is being taken to the surgical unit following surgery. Which identified client problem should the nurse address first?

Accepted Answer

Answer reason: In sickle cell disease, hypoxia is a major trigger for sickling and can precipitate acute chest syndrome, making early support of ventilation and secretion clearance especially urgent. Addressing airway clearance (positioning, oxygen as ordered, incentive spirometry, effective pain control to allow deep breathing, and monitoring respiratory status) directly reduces the risk of respiratory compromise and sickling-related complications. Fluid deficits and skin issues are important but are typically less immediately life-threatening than an airway problem in the post-op period, and anxiety is a lower physiologic priority.

Question 4

What is the most important action for a nurse to take when caring for a client who had a liver biopsy?

Accepted Answer

Answer reason: Post–liver biopsy care prioritizes early detection of hemorrhage because the liver is highly vascular and bleeding can rapidly become life-threatening. Tachycardia with hypotension is a key compensatory pattern indicating possible hypovolemia and shock, requiring immediate intervention and escalation. Pain assessment is important, but it is secondary to surveillance for acute complications; new or increasing right shoulder/abdominal pain would further raise concern for bleeding, but vital-sign trends are the fastest objective cue. Teaching and psychosocial assessments are appropriate later once physiologic stability is assured.

Question 5

An amniotomy is performed on a client in labor. Following this procedure, what is the priority nursing intervention?

Accepted Answer

Answer reason: Amniotomy can precipitate umbilical cord prolapse or acute cord compression due to sudden release of amniotic fluid and loss of buoyancy around the cord. The earliest and most sensitive indicator of these complications is a sudden change in fetal heart rate pattern, so immediate assessment of fetal heart tones is the priority. Prompt detection allows rapid interventions (e.g., repositioning, elevating presenting part, calling for assistance) to prevent fetal hypoxia. Comfort measures and ambulation may be appropriate later but are not time-critical compared with confirming fetal status immediately after membrane rupture.

Question 6

The nurse is helping a client to bed when the client begins having a generalized seizure. Which action should the nurse take first?

Accepted Answer

Answer reason: The first priority during a generalized seizure is immediate safety and airway protection to reduce risk of trauma and aspiration. Lowering the client to the floor prevents falls from the bed and the side-lying position promotes drainage of secretions and helps maintain a patent airway. Putting any object in the mouth risks dental injury and airway obstruction, and restraining the client can cause musculoskeletal injury. Provider notification is appropriate after the client is safe and the seizure is assessed and documented.

Question 7

A client with left-sided heart failure is to be maintained on bed rest. What is the rationale for maintaining the client on bed rest?

Accepted Answer

Answer reason: Bed rest decreases metabolic demand and sympathetic stimulation, which lowers heart rate and myocardial oxygen consumption. In left-sided heart failure, minimizing exertion reduces preload/afterload stress and helps prevent worsening pulmonary congestion and dyspnea. This intervention is a preventive measure aimed at reducing the risk of decompensation while other therapies (e.g., diuretics, vasodilators) take effect. Increasing blood pressure is not a therapeutic goal in typical left-sided failure, and bed rest does not directly “improve pumping action” beyond reducing the workload that aggravates impaired function.

Question 8

A client who is rushed to the emergency department is diagnosed with a ruptured aortic aneurysm. Which intervention should the nurse expect for this client?

Accepted Answer

Answer reason: A ruptured aortic aneurysm is an immediately life-threatening hemorrhage that requires definitive control of bleeding, most often via emergent open or endovascular repair. The nurse should anticipate rapid escalation to surgery along with aggressive resuscitation and hemodynamic monitoring because delaying definitive repair markedly increases mortality. Antihypertensives or beta-blockers may be used in unruptured aneurysm/dissection to reduce shear stress, but they do not treat active rupture and can worsen perfusion in profound hypovolemia. An arteriogram may help diagnose a stable aneurysm, but in a confirmed rupture the priority is urgent operative management rather than additional imaging.

Question 9

The nurse cares for a client following a modified left radical mastectomy in the treatment of breast cancer. Which is the proper position for the nurse to place the client’s left arm?

Accepted Answer

Answer reason: After mastectomy with lymph node dissection, venous and lymphatic drainage from the affected arm can be impaired, increasing the risk of edema and lymphedema. Positioning the arm at heart level promotes venous return without excessive dependent pooling while avoiding overly aggressive elevation that can stress the shoulder and surgical site early post-op. Keeping the extremity dependent would worsen swelling due to gravity. Elevating above the shoulder is not the routine immediate post-op position and can contribute to discomfort and shoulder strain if done prematurely.

Question 10

The nurse assesses a client who is in an arm cast. The client complains of severe pain, decreased motion and sensation, and swelling in the fingers. Which action should the nurse take first?

Accepted Answer

Answer reason: These findings (severe pain with swelling and sensory/motor changes) suggest neurovascular compromise from increasing edema under the cast, which can rapidly progress to compartment syndrome. The priority is an immediate nursing action that can reduce swelling and improve perfusion while further evaluation is initiated. Elevating the extremity helps decrease venous congestion and tissue edema, potentially relieving pressure on nerves and vessels. Giving analgesics can mask worsening ischemic pain, and removing/bivalving a cast is typically a provider-directed action (or done per protocol), so initial elevation and prompt reassessment/notification follow.

Question 11

The nurse checks gastric residual prior to administering an intermittent tube feeding through a nasogastric tube. The nurse understands that this is necessary to?

Accepted Answer

Answer reason: Checking gastric residual assesses gastric emptying/tolerance of the previous feeding, which helps prevent regurgitation and aspiration when giving the next bolus. A high residual suggests delayed gastric motility and that the prior formula has not moved forward adequately, signaling increased risk for vomiting and aspiration. Tube placement is confirmed by appropriate methods (e.g., radiography initially, pH testing per policy), not by residual volume alone. The goal is to identify poor tolerance early so the nurse can hold or adjust the feeding and notify the provider per protocol.

Question 12

A client expectorates pink-tinged sputum after returning from a bronchoscopy. Which action is most appropriate for the nurse to take?

Accepted Answer

Answer reason: Pink-tinged sputum in small amounts is an expected finding after bronchoscopy due to minor mucosal irritation from the scope and biopsy/brushings. The priority is to observe for progression to complications such as significant bleeding, respiratory distress, hypoxia, or hemodynamic instability, which would change management. Immediate provider notification is not indicated for mild blood-tinged sputum alone without other concerning signs. A focused assessment (including vitals and respiratory status) is appropriate as part of ongoing monitoring, but the best single action given the expected finding is continued observation for deterioration.

Question 13

Which client is least likely to develop third spacing?

Accepted Answer

Answer reason: Third spacing occurs when fluid shifts from the intravascular space into the interstitial/third spaces due to decreased oncotic pressure, increased capillary permeability, or lymphatic obstruction. Cirrhosis and end-stage liver disease commonly cause hypoalbuminemia and portal hypertension, promoting ascites and edema via reduced plasma oncotic pressure and altered hydrostatic forces. Chronic kidney disease can lead to sodium and water retention and can be associated with protein loss or low albumin states, also increasing edema risk. Diabetes mellitus alone is not a typical primary driver of third spacing unless complicated by conditions like nephrotic syndrome, severe infection, or critical illness.

Question 14

The nurse working in an outpatient clinic cares for a client immediately after a sigmoidoscopy. Which sign and symptom should be most concerning to the nurse?

Accepted Answer

Answer reason: Post-procedure assessment prioritizes early detection of complications such as bleeding, perforation, or a vasovagal reaction that can lead to hemodynamic instability. New dizziness/light-headedness suggests hypotension or poor perfusion and requires immediate vital-sign assessment, orthostatic evaluation, and prompt escalation. In contrast, mild cramping and a sense of fullness are common after lower endoscopy due to air insufflation and typically resolve without intervention. Grogginess can occur if sedation was used, but when paired with dizziness it is the circulatory symptom that most strongly signals a potential complication needing urgent evaluation.

Question 15

The nurse cares for a client in Buck’s traction. The nurse understands that it is important to ensure the weights hang free to?

Accepted Answer

Answer reason: Traction works only when there is a constant, uninterrupted pulling force applied along the line of the bone. If the weights rest on the bed or floor, the effective traction force is reduced or lost, allowing the fracture/hip to slip out of alignment and increasing pain and risk of complications. Keeping the weights hanging freely preserves the intended countertraction and maintains reduction and alignment. Preventing skin breakdown and muscle spasm relief are important aspects of care, but they are not the primary mechanical reason for ensuring the weights hang free.

Question 16

A client is admitted to the hospital due to complications of cardiomyopathy. The client states, “I am always being admitted to the hospital for the same problem.” The nurse knows that which recurring condition develops in clients with cardiomyopathy?

Accepted Answer

Answer reason: Cardiomyopathy impairs the heart’s ability to contract and/or relax effectively, leading to reduced cardiac output and progressive ventricular dysfunction. As compensatory mechanisms eventually fail, clients commonly develop recurrent episodes of decompensated congestive heart failure with fluid overload, pulmonary congestion, and poor perfusion, prompting repeated hospitalizations. Hypertension can be a cause of some cardiomyopathies but is not the typical recurring complication once cardiomyopathy is established. Myocardial infarction and anemia may coexist but are not the characteristic repetitive complication pattern linked directly to cardiomyopathy progression.

Question 17

The nurse instructs the client how to perform foot pumps (extension and flexion of the foot at the ankle). The nurse knows that contracting the leg muscles helps to prevent which postoperative complication?

Accepted Answer

Answer reason: Ankle flexion/extension activates the calf muscle pump, which increases venous return and reduces venous stasis in the lower extremities. Venous stasis is a key element of Virchow’s triad and is a major contributor to postoperative clot formation, especially with immobility. Regular foot pumps therefore lower the risk of thrombus development in deep leg veins. Pneumonia prevention is more directly addressed by coughing, deep breathing, and incentive spirometry rather than lower-extremity exercises.

Question 18

A client is admitted to the hospital with a decubitus ulcer in the sacral area. The client is bed ridden and refuses to eat. The nurse realizes that the client is at risk for which complication?

Accepted Answer

Answer reason: Wound healing requires adequate calories, protein, vitamins (especially A and C), zinc, and sufficient hydration to support collagen synthesis, angiogenesis, and immune function. A bedridden client with an existing pressure injury already has compromised tissue perfusion; refusing to eat further worsens malnutrition and directly delays granulation and epithelialization. This combination increases risk of wound deterioration and secondary infection, making delayed healing the most likely complication. Fluid volume deficit is possible if intake is also low, but the stem emphasizes refusal to eat in the context of a pressure ulcer, pointing most strongly to healing impairment rather than acute hypovolemia.

Question 19

A client has a nasogastric (NG) tube placed after abdominal surgery. Which finding indicates the NG tube may be removed?

Accepted Answer

Answer reason: Return of bowel function after abdominal surgery is best evidenced by passage of flatus, indicating peristalsis has resumed and gastric/intestinal decompression is no longer required. NG tubes placed postoperatively are typically maintained until signs of resolving ileus appear to reduce nausea/vomiting and aspiration risk. Decreased drainage volume alone can occur despite ongoing ileus and is not a reliable marker of GI motility. Subjective improvement in nausea or burping can occur without full return of lower GI function and therefore is less dependable for removal decisions.

Question 20

Which client is at least risk for acquiring pneumonia during hospitalization?

Accepted Answer

Answer reason: Hospital-acquired pneumonia risk increases with impaired airway clearance, immobility, and reduced lung expansion/atelectasis. Frequent ambulation promotes deeper ventilation, improves cough effectiveness, mobilizes secretions, and reduces atelectasis, making pneumonia less likely. By contrast, immunocompromise (HIV) and older age with diabetes are associated with reduced host defenses and higher infection risk. Buck’s traction typically limits mobility, which increases stasis of secretions and predisposes to pulmonary complications.

Question 21

A client is admitted to the nursing unit after experiencing a cerebral vascular accident. The client is unconscious. What is the nurse’s priority intervention?

Accepted Answer

Answer reason: Unconscious clients are at immediate risk for airway obstruction and aspiration because protective reflexes (gag/cough) and tongue tone can be diminished after a stroke. Using ABC priorities, ensuring ventilation and oxygenation prevents rapid deterioration from hypoxia, which can worsen neurologic injury. Airway interventions (positioning, suctioning as needed, supplemental oxygen, and escalation for advanced airway support) address the most time-critical complication. Measures like skin care, mobility/atrophy prevention, and hydration are important but are secondary once airway and breathing are stabilized.

Question 22

The nurse cares for a client who experienced a cerebral vascular accident. The client’s husband asks why his wife has a splint on her hand. The nurse explains that the splint is needed to prevent?

Accepted Answer

Answer reason: After a stroke, weakness and spasticity can cause the hand to assume a flexed posture, increasing the risk of contractures and permanent malposition. A hand splint maintains functional alignment and provides sustained positioning to prevent shortening of muscles/tendons and joint stiffness. While edema control may be helped by elevation or exercises, splinting is primarily a contracture-prevention strategy. Muscle wasting is better addressed with mobility, therapy, and strengthening rather than a static splint alone.

Question 23

The nurse cares for client who is status post lung transplant. The client has a double thoracotomy incision. Which drug may impair healing of the incision?

Accepted Answer

Answer reason: Glucocorticoids can delay wound healing by suppressing the inflammatory phase of healing, decreasing fibroblast activity and collagen synthesis, and impairing angiogenesis. Post-transplant clients often require immunosuppression, which further increases infection risk and slows tissue repair, making this effect clinically important for a thoracotomy incision. A loop diuretic may contribute to fluid/electrolyte issues but is not a direct, common cause of impaired incision healing. Potassium supplementation and stool softeners do not typically interfere with the biologic processes of wound repair.

Question 24

A client with an arm cast complains of severe pain in the affected extremity, and decreased sensation and motion are noted. Swelling in the fingers is also increased. What is the most important intervention?

Accepted Answer

Answer reason: The priority nursing action is to obtain immediate medical evaluation for cast bivalving/splitting or other urgent decompression orders. Elevation and analgesics can delay definitive treatment and may mask worsening ischemia, and nursing staff typically cannot independently remove a cast. Rapid escalation is essential to prevent irreversible nerve and muscle damage.

Question 25

Which instruction should a nurse include in the teaching plan for a client with a platelet count of 25,000/mm3 and petechial rash on the legs, arms, and neck?

Accepted Answer

Answer reason: A platelet count of 25,000/mm3 indicates severe thrombocytopenia with high bleeding risk, and petechiae are a classic sign of capillary bleeding. Teaching should focus on preventing hemorrhage by avoiding medications that impair platelet function. Aspirin irreversibly inhibits platelet aggregation and can significantly worsen bleeding risk, so a non–platelet-inhibiting analgesic is preferred. Acetaminophen provides pain/fever relief without antiplatelet effects at usual doses, making it the safer choice compared with NSAIDs/aspirin in thrombocytopenia.

Question 26

Which statement by a client with chronic arterial disease indicates to the nurse further teaching is needed?

Accepted Answer

Answer reason: Clients with chronic arterial disease have impaired peripheral circulation and reduced sensation, increasing risk for ischemic injury and burns. Safety teaching emphasizes avoiding temperature extremes (especially direct heat sources like heating pads, hot water bottles, or very hot baths) because tissue damage can occur before the client feels it. Keeping the entire house at a high temperature is not a targeted evidence-based strategy and may encourage unsafe warming practices rather than promoting protective behaviors (layering socks/blankets, keeping feet warm without direct heat). In contrast, smoking cessation, routine foot care, and graded walking improve perfusion and reduce progression/complications of peripheral arterial disease.

Question 27

Which intervention should a nurse include in the care plan for a 2-year-old child with Wilms’ tumor?

Accepted Answer

Answer reason: Wilms’ tumor creates a major risk of hemorrhage and tumor rupture with manipulation, so nursing care prioritizes preventing abdominal trauma and preparing the child/family for prompt definitive treatment. Nephrectomy is typically scheduled promptly once stabilized and staged, and communicating the expected near-term surgery supports preparation and reduces delays. Abdominal palpation is avoided because it can precipitate rupture and dissemination of malignant cells. Massaging the abdomen and applying a tight binder also increase pressure/manipulation and can worsen pain or increase risk of rupture.

Question 28

Which statement indicates to the nurse that a client with diabetes understands proper foot care?

Accepted Answer

Answer reason: Diabetic neuropathy and peripheral vascular disease increase risk for unrecognized pressure injury and ulceration, so prevention focuses on minimizing friction, pressure, and skin breakdown. Properly fitting shoes and clean cotton socks reduce rubbing, help keep skin dry, and protect from minor trauma that can progress to infection. Going barefoot is unsafe because small cuts or burns may not be felt and can ulcerate. Rotating injection sites should be done in recommended areas (e.g., abdomen, thigh, upper arm), not the feet, and foot aching is a late, nonspecific trigger compared with daily inspection and protective footwear.

Question 29

Two days after a transrectal biopsy of the prostate, a client calls the clinic to report that his stool is streaked with blood. Which response by the nurse is appropriate?

Accepted Answer

Answer reason: A small amount of rectal bleeding or blood-streaked stool can occur for several days after a transrectal prostate biopsy due to local tissue trauma along the needle path. When bleeding is minimal and there are no other warning signs (e.g., heavy bleeding, dizziness, fever, severe pain), the appropriate nursing response is reassurance and reinforcing expected post-procedure findings. Asking the client to come in immediately is more appropriate if bleeding is persistent/heavy or accompanied by systemic symptoms suggesting complications. Giving a laxative is not indicated and could worsen irritation or bleeding if it leads to increased bowel activity or diarrhea.

Question 30

When performing a physical assessment, the nurse discovers a client’s urinary drainage bag lying next to him. Based on this finding, the nurse identifies which priority nursing diagnosis?

Accepted Answer

Answer reason: Finding the bag lying next to the client suggests it may be positioned at or above bladder level and may also contact nonsterile surfaces, increasing catheter-associated UTI risk. This represents a preventable complication with potential for rapid clinical deterioration (fever, pyelonephritis, sepsis), so it takes priority over comfort or dignity concerns. Reflex incontinence is not supported by the finding because the issue is catheter drainage system positioning, not an involuntary bladder contraction pattern.

Question 31

A client is to undergo a kidney transplantation with a living donor. What is the most important preoperative assessment by the nurse?

Accepted Answer

Answer reason: Preoperatively, the nurse’s priority is to identify fever, respiratory symptoms, urinary symptoms, abnormal drainage, or other findings that indicate infection so they can be treated before immunosuppression begins. Graft rejection is not a preoperative issue because the transplanted kidney has not yet been implanted. Urine output and psychosocial readiness are important baseline and planning assessments, but they do not pose the same immediate threat to safe proceeding with surgery as an untreated infection.

Question 32

An intubated client with full-thickness, circumferential burns to the chest is experiencing pressure from edema that is inhibiting chest wall expansion. The nurse anticipates that which of the following is the priority intervention for the client?

Accepted Answer

Answer reason: The priority is to restore adequate thoracic excursion and prevent ventilatory failure by surgically releasing the constriction. An escharotomy relieves pressure by incising the eschar, improving compliance and ventilation/oxygenation. Needle thoracentesis and chest tube insertion treat pleural air or fluid (e.g., pneumothorax/hemothorax), which is not the mechanism described. Cricothyrotomy addresses an upper-airway obstruction, but the client is already intubated and the problem is restrictive chest wall expansion.

Question 33

The nurse is preparing to care for the client immediately after a Whipple procedure. The nurse should plan to include which action?

Accepted Answer

Answer reason: Immediate postoperative care prioritizes detecting complications early through focused monitoring tied to the altered physiology of pancreatic resection. Routine glucose monitoring guides timely insulin or dextrose adjustments and helps prevent poor wound healing and infection associated with uncontrolled glucose. Enteral feeds are not typically initiated immediately without specific orders and tolerance assessment, and NG tubes placed for decompression are usually not irrigated unless prescribed to avoid disrupting anastomoses.

Question 34

The nurse is caring for the client with acute diverticulitis. Which finding should most prompt the nurse to consider that the client has developed an intestinal perforation?

Accepted Answer

Answer reason: Intense pain suggests new peritoneal irritation from leakage of bowel contents and is more concerning than baseline diverticulitis discomfort. Fever and leukocytosis commonly occur with uncomplicated diverticulitis and are not specific for perforation. Absent bowel sounds may occur later with ileus in generalized peritonitis, but the more immediate red-flag change that should prompt suspicion is a marked escalation in abdominal pain.

Question 35

The nurse is teaching the client who is a strict vegetarian how to decrease the risk of developing megaloblastic anemia. Which information should the nurse provide?

Accepted Answer

Answer reason: Strict vegetarians are at particular risk for vitamin B12 deficiency because natural dietary sources are primarily animal products. Preventing deficiency with appropriate supplementation addresses the actual mechanism and is the most effective risk-reduction teaching. Increasing iron targets microcytic anemia rather than macrocytic megaloblastic anemia, and routine Schilling testing or monthly hemoglobin checks are not first-line prevention strategies.

Question 36

The nurse learns in report that the client admitted with a vertebral fracture has a halo external fixation device in place. Which intervention should the nurse plan?

Accepted Answer

Answer reason: Cleaning the pin entry sites helps reduce bacterial colonization and allows early identification of redness, drainage, loosening, or pain that can signal infection or instability. The vest should remain in place to maintain cervical alignment and prevent neurologic injury. Pin tightening is performed only per provider protocol (often by trained personnel) because over-tightening can cause skull penetration or loosening and increases complication risk.

Question 37

The nurse notes bright red blood and clots in the client’s urine after a cystoscopy. Which is the most appropriate initial action by the nurse?

Accepted Answer

Answer reason: Bright red urine with clots after cystoscopy suggests active bleeding and a risk of urinary outflow obstruction, making this a potential post-procedure complication that requires prompt evaluation. The priority is to escalate care so the provider can assess for ongoing hemorrhage, consider hemostatic measures, and determine whether interventions like catheter placement/continuous bladder irrigation are indicated. Initiating bladder irrigation independently may be outside nursing scope depending on orders and can worsen bleeding or disrupt clot formation if not clinically appropriate. Heat and antispasmodics address discomfort/spasm but do not address the immediate risk of significant bleeding and clot retention.

Question 38

The nurse is caring for the client with CRF. Which statement should the nurse document as an appropriate outcome in the plan of care?

Accepted Answer

Answer reason: An outcome stating absence of bleeding is clinically meaningful and directly reflects control of a common complication of advanced kidney disease. Daily weight gain up to 3 pounds is excessive for most CRF patients and suggests fluid overload rather than effective management. Reduced serum albumin would indicate worsening nutritional/protein status, not improvement, and “three large meals” is often unrealistic because uremia commonly causes anorexia and nausea; smaller, more frequent meals are typically better tolerated.

Question 39

While performing tracheostomy care for the client who experienced facial trauma, the nurse discovers that more air is needed to inflate the cuff to maintain a seal. Which complication related to the tracheostomy should the nurse further explore?

Accepted Answer

Answer reason: Excessive cuff pressure and prolonged cuff inflation can cause ischemia and cartilage damage, leading to airway softening and collapse/dilation consistent with this complication. This finding is not typical of stenosis, which narrows the airway and would not usually require increasing cuff volume to seal. A tracheal-innominate artery fistula classically presents with sentinel bleeding and massive hemorrhage rather than a slowly increasing cuff inflation requirement.

Question 40

In the process of preparing the client for discharge after cesarean section, the nurse addresses all of the following areas during discharge education. Which should be the priority advice for the client?

Accepted Answer

Answer reason: Incision management directly targets the highest immediate risks—wound infection, dehiscence, and poor healing—and includes keeping the site clean/dry, activity limits, pain expectations, and when to seek care for fever, redness, drainage, or separation. Compared with general advice about rest, infant care, or arranging help at home, incision care has the most direct impact on maternal surgical safety and reduces avoidable readmissions. This prioritization aligns with focusing first on physiologic risk reduction before broader recovery and parenting guidance.

Question 41

The nurse is preparing the 4-month-old diagnosed with intussusception for surgery when the infant passes a normal brown stool. What is the nurse’s most important action?

Accepted Answer

Answer reason: Because intussusception carries high risk of ischemia, perforation, and rapid deterioration, the priority is to promptly communicate this new finding so the provider can reassess and decide whether urgent imaging, enema reduction, or proceeding with surgery is indicated. Nurse-initiated actions like palpating the abdomen or checking for visible blood are secondary assessments and do not address the need for timely medical decision-making. Documentation is appropriate but not the priority when a new finding could alter management and prevent unnecessary or delayed intervention.

Question 42

A client with gastric cancer anticipates having surgery for a gastric resection. What is the most important nursing intervention during the preoperative period?

Accepted Answer

Answer reason: Gastric cancer commonly causes anorexia, early satiety, weight loss, and protein-calorie deficiencies, so optimizing nutrition preoperatively is a key modifiable factor that improves surgical outcomes. Interventions include assessing weight/labs, collaborating with dietetics, and supporting high-calorie/high-protein intake or enteral/parenteral support as ordered. DVT prevention is important but is typically addressed perioperatively for all major surgeries; correcting malnutrition is the most targeted priority for this specific population. Teaching about radiation is not universally indicated preop and depends on the treatment plan.

Question 43

A nurse is providing instructions to a client who will undergo a liver biopsy the next morning. The client asks the nurse about what potential problems could occur. It is most important for the nurse to provide information for which condition?

Accepted Answer

Answer reason: Injury to hepatic vessels can cause internal hemorrhage and rapid hemodynamic compromise, so pre-procedure teaching should emphasize this risk and the need to report symptoms such as increasing right upper quadrant/shoulder pain, dizziness, or signs of shock. Other options like constipation or paralytic ileus are not characteristic primary complications of liver biopsy and are far less immediately dangerous. Renal shutdown is not a typical direct complication of the biopsy compared with bleeding risk, especially in patients with potential coagulopathy from liver disease.

Question 44

The nurse is teaching the family of a client newly diagnosed with multiple myeloma. The nurse determines that teaching has been effective when the family states the importance of?

Accepted Answer

Answer reason: Multiple myeloma can cause excess light chains and hypercalcemia, increasing the risk of renal tubular damage and acute kidney injury. Generous oral hydration supports renal perfusion and urine flow, helping flush nephrotoxic proteins and reduce calcium concentration. Fluid restriction would worsen dehydration and increase the likelihood of kidney complications. Bed rest and leg elevation do not address the primary early preventable complication emphasized in patient teaching for this condition.

Question 45

A client with a right hip fracture is complaining of left-sided leg pain and edema and has a positive Homans’ sign. Based on the clinical findings, which of the following potential complications is a priority for the nurse to address?

Accepted Answer

Answer reason: Unilateral calf pain/edema with a positive Homan’s sign is most consistent with a suspected deep vein thrombosis, which can embolize to the lungs and rapidly cause hypoxemia, hemodynamic instability, and death. Therefore the nurse’s priority concern is progression to a pulmonary embolism and the need for urgent escalation/monitoring for respiratory compromise. Fat embolism is classically associated with long-bone fractures and presents with respiratory distress plus neurologic changes and petechiae rather than isolated calf findings. Infection is important but is not the most immediate risk indicated by these specific signs.

Question 46

A 40-year-old client asks the nurse what may increase the risk for the development of cataracts. The best response by the nurse is?

Accepted Answer

Answer reason: Corticosteroids are a well-established risk factor for cataract formation, particularly posterior subcapsular cataracts, due to their effects on lens metabolism and protein structure over time. This makes chronic systemic, inhaled, or high-dose topical steroid exposure an important modifiable risk to assess in patient history. Increased intraocular pressure is more directly linked to glaucoma rather than cataracts, even though both can cause visual changes. Maternal rubella exposure is associated with congenital cataracts in the infant, not new cataract development in a 40-year-old client. Recurrent streptococcal infections are not a recognized cataract risk factor.

Question 47

The nurse is teaching a client newly diagnosed with glaucoma about the importance of medication compliance. The nurse determines that teaching has been effective when the client states that noncompliance may result in?

Accepted Answer

Answer reason: Glaucoma causes chronically elevated intraocular pressure that damages the optic nerve, and this injury is irreversible once it occurs. Medication adherence is aimed at lowering intraocular pressure to slow or prevent ongoing optic nerve damage. If therapy is not taken as prescribed, visual field loss can progress and ultimately lead to irreversible blindness. Diplopia and pupillary constriction are not the characteristic consequences of untreated glaucoma and do not represent the key long-term risk being prevented.

Question 48

A client is diagnosed with active tuberculosis and started on triple antibiotic therapy. The nurse would be concerned if the client demonstrates which of the following?

Accepted Answer

Answer reason: Persistently positive AFB at 2 months suggests ongoing infectiousness, possible nonadherence, malabsorption, incorrect regimen, or drug-resistant TB. This finding increases risk for treatment failure and continued transmission, prompting evaluation of adherence, repeat cultures with sensitivities, and potential regimen changes. The other findings reflect clinical/radiographic improvement or a symptom that can persist without indicating treatment failure early in therapy.

Question 49

The nurse is planning care for a client who has undergone a total knee replacement. The most important intervention to prevent the development of a pulmonary embolism would be?

Accepted Answer

Answer reason: Mobilizing the patient as early and as safely as possible promotes venous return via the calf muscle pump, reducing stasis and clot formation risk. The other choices focus on detection (imaging) or treating respiratory failure (intubation) rather than preventing clot development. Therefore, prioritizing early ambulation is the most direct nursing intervention to prevent a pulmonary embolism in this postoperative setting.

Question 50

The nurse is preparing to discharge a child after cardiac catheterization. What is the most important information for the nurse to provide?

Accepted Answer

Answer reason: After cardiac catheterization, a key discharge priority is preventing renal and vascular complications from contrast exposure and the puncture site. Encouraging increased oral fluids promotes clearance of contrast dye and helps reduce dehydration-related kidney stress, making it the most broadly important, safety-focused instruction. Activity-related options (sports, school) are individualized and commonly restricted initially to decrease bleeding/hematoma risk at the access site. Bathing guidance varies by facility and timing (often avoiding soaking), so it is less universally critical than hydration and routine diet unless specific wound-care directions are given.

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