Question 1

The nurse is caring for 3-year-old client who has a high red blood cell count and polycythemia. The most important intervention for the nurse to include in the plan of care would be?

Accepted Answer

Answer reason: Promoting adequate hydration helps reduce relative hemoconcentration and supports circulatory flow, making it a high-priority, preventive nursing intervention. Analgesics do not address the core complication risk unless pain is present and ordered. A soft toothbrush is more aligned with thrombocytopenia/bleeding-risk care, not the primary problem of hyperviscosity.

Question 2

A small child has undergone surgical repair of a cleft palate and is ready for discharge. What is the most important information for the nurse to tell the parents?

Accepted Answer

Answer reason: The core priority after cleft palate repair is protecting the surgical site from disruption to prevent bleeding, dehiscence, and fistula formation. Arm restraints (“no-no’s”) reduce the child’s ability to put fingers or objects into the mouth and traumatize the incision during the high-risk early healing period. Dietary guidance and oral care are important, but they are secondary to preventing direct mechanical injury to the repair. Drinking method restrictions are typically focused on avoiding sucking and objects that contact the palate rather than a blanket prohibition on cups.

Question 3

To prevent tissue infection and breakdown after cleft palate or lip repair, a nurse should use which intervention?

Accepted Answer

Answer reason: Post–cleft repair care prioritizes protecting the incision by reducing contamination and local irritation that can lead to wound dehiscence and infection. Gentle oral rinsing after feeds helps clear milk/formula residue and decreases bacterial load around the operative site without adding mechanical stress. Allowing sucking (eg, pacifier use) increases tension on the repair and raises breakdown risk. Keeping a suture line “moist at all times” is not the key prevention strategy and can macerate tissue if overdone, whereas careful cleansing is targeted risk reduction.

Question 4

A child with appendicitis reports a sudden cessation of abdominal pain to the nurse. What is the most appropriate intervention by the nurse?

Accepted Answer

Answer reason: A sudden decrease or cessation of pain in suspected appendicitis is a classic warning sign for possible appendix rupture with leakage of infectious contents into the peritoneum. This represents an acute complication risk requiring rapid escalation of care, maintaining NPO status, and preparing for urgent operative management. Immediate surgical preparation helps minimize progression to peritonitis, sepsis, and shock. Options suggesting discharge, oral intake, or increased activity are unsafe because they assume improvement rather than recognizing potential perforation and clinical deterioration.

Question 5

A neonate has been diagnosed with a unilateral complete cleft lip and cleft palate. The nurse formulating the care plan for this neonate will have which nursing diagnosis as a priority?

Accepted Answer

Answer reason: A cleft palate prevents adequate separation of the oral and nasal cavities, making it difficult to generate suction and increasing the chance that milk will pool and enter the airway during feeding. This creates an immediate, high-risk complication compared with longer-term concerns like growth delays. Infection risk and skin integrity issues can occur, but they are secondary to preventing aspiration and maintaining safe feeding and breathing.

Question 6

Which goal should be achieved by performing a craniotomy on a client with Reye’s syndrome?

Accepted Answer

Answer reason: A craniotomy (or decompressive procedure) is aimed at relieving intracranial hypertension by allowing the swollen brain more room, thereby improving cerebral perfusion and preventing secondary neurologic injury. Lowering carbon dioxide is a ventilatory strategy, not the purpose of opening the skull. Continuous ICP monitoring is typically achieved via an intraventricular catheter or bolt rather than requiring a craniotomy as the primary goal.

Question 7

The goal of nursing care for a client with Reye’s syndrome is to minimize intracranial pressure (ICP). Which nursing intervention helps to meet this goal?

Accepted Answer

Answer reason: Avoiding neck flexion keeps the jugular veins unobstructed, promoting venous drainage from the brain and helping limit intracranial blood volume. Keeping the head of bed flat can impede venous return and may worsen ICP, whereas frequent position changes can provoke stimulation and transient ICP spikes. Suctioning and chest physiotherapy can also increase ICP through coughing/valsalva and should be minimized or performed only when necessary with appropriate precautions.

Question 8

The nurse is providing discharge instructions for a client who is receiving chemotherapeutic medications. The nurse is aware that which intervention is most important to prevent hemorrhagic cystitis?

Accepted Answer

Answer reason: The key nursing prevention strategy is to dilute urine and promote frequent bladder emptying to reduce contact time between the toxin and the bladder lining. Encouraging higher oral fluid intake (and often scheduled voiding) supports increased urine output and bladder flushing, lowering bleeding risk. Antibiotics do not prevent chemically induced cystitis, and restricting fluids would concentrate urine and increase mucosal exposure, worsening risk; antacids are unrelated to this complication.

Question 9

A child with hemophilia is hospitalized with bleeding into the knee. Which action should the nurse take first?

Accepted Answer

Answer reason: Acute hemarthrosis in hemophilia requires immediate measures that minimize further bleeding and reduce swelling while definitive factor replacement is arranged. Elevation decreases hydrostatic pressure and venous congestion at the joint, helping limit ongoing bleeding and pain as an initial nursing action. Active ROM is contraindicated during active joint bleeding because it can worsen hemorrhage and joint damage; activity is typically restricted and the joint protected. Transfusion options are not the first nursing action for localized hemarthrosis, and whole blood is generally unnecessary; targeted clotting factor replacement is preferred, with plasma used only if factor concentrates are unavailable.

Question 10

Which nursing intervention is a priority for a hemophilic child who has fallen and badly bruised his leg?

Accepted Answer

Answer reason: Direct pressure helps control local bleeding, and prompt replacement of the missing clotting factor treats the underlying coagulation defect and stops further bleeding. NSAIDs and aspirin inhibit platelet function and can worsen bleeding risk, making them unsafe choices in this setting. Heat promotes vasodilation and can increase bleeding; initial care is focused on controlling bleeding and administering factor replacement as ordered.

Question 11

The nurse is caring for a child with a newly applied wet hip-spica cast. What is the most important nursing intervention?

Accepted Answer

Answer reason: A newly applied wet hip-spica cast places the child at high risk for pressure injury and compromised circulation from sustained pressure points while the cast is drying and molding. Frequent repositioning helps prevent skin breakdown, supports even drying, and reduces the chance of localized neurovascular compression. Using an abductor bar to move the child can damage the bar or disrupt cast integrity, and covering a wet cast with plastic traps moisture and heat, delaying drying and increasing skin maceration risk. Handling with palms rather than fingertips is important to avoid indentations, but preventing pressure-related complications through scheduled turning is the higher-priority intervention.

Question 12

Which nursing diagnosis has the highest priority in a 6-year-old child who had a plaster cast applied 6 hours ago to the left leg for a fracture of the tibia?

Accepted Answer

Answer reason: A plaster cast applied 6 hours ago places the child at increased risk for impaired circulation and nerve compression, which can progress to compartment syndrome and irreversible damage if not detected promptly. This diagnosis drives frequent neurovascular assessments (pain out of proportion, pallor, paresthesia, pulselessness, paralysis, poikilothermia), elevation as prescribed, and rapid escalation for cast splitting/bivalving if compromise is suspected. Mobility limits and self-care deficits are expected but are not immediately life/limb-threatening. Teaching is important but is secondary to preventing acute neurovascular injury.

Question 13

A nurse is caring for a child who received a hip-spica cast 24 hours ago for hip dysplasia. Which nursing diagnosis should the nurse give the highest priority?

Accepted Answer

Answer reason: Neurovascular impairment can rapidly progress to ischemia and permanent tissue or nerve damage if not identified and treated promptly. At 24 hours post-application, frequent assessment of distal color, temperature, capillary refill, pulses, movement, and sensation is essential, and escalating concerns for cast bivalving is urgent. Skin breakdown and urinary issues are important but generally develop less emergently than threatened limb perfusion/innervation. Impaired gas exchange is not the most likely priority problem specifically attributable to a hip-spica cast in an otherwise stable child.

Question 14

After assisting the primary health care provider in applying a cast, a nurse should include which intervention in the immediate cast care?

Accepted Answer

Answer reason: A newly applied plaster cast is soft and vulnerable to indentation, which can create pressure points and increase the risk of skin breakdown and neurovascular compromise. Using the palms distributes pressure evenly and helps maintain proper cast shape while it sets. Resting the cast on a hard surface or handling it with fingertips can deform the cast and concentrate pressure in a small area. Plaster water should not be poured into sinks due to clogging risk, and surrounding skin should be cleaned promptly to remove wet plaster before it dries and irritates skin.

Question 15

A child in skeletal traction for a fracture of the right femur exhibits a positive Homans’ sign, complains of left-sided leg pain, and has edema in the left leg. A nurse should further assess the child for which condition?

Accepted Answer

Answer reason: Unilateral calf/leg pain with edema is a classic presentation consistent with a thrombus obstructing venous return, and a positive Homans’ sign is a supportive (though non-specific) finding that should heighten suspicion. This complication is particularly important because an undetected clot can embolize to the lungs and become life-threatening. Infection would more typically present with fever, localized warmth, drainage, or systemic inflammatory signs rather than isolated unilateral swelling and pain. Fat embolism syndrome is usually characterized by acute respiratory distress and neurologic changes with petechiae after long-bone fracture, not isolated unilateral leg edema.

Question 16

The HCP writes an order to hold all medications the morning of surgery for the client with a history of type 1 DM and hypertension. The nurse should clarify the hold order for which medication(s)?

Accepted Answer

Answer reason: Pre-op insulin usually requires adjustment (e.g., reduced intermediate/basal dose and holding or modifying short-acting depending on glucose and timing), not a blanket hold. Therefore the nurse should clarify an order that instructs holding these doses without an individualized plan and glucose monitoring. By contrast, several other routine morning meds may appropriately be held before surgery based on bleeding risk, hemodynamics, or anesthesia plan, but insulin in type 1 requires specific perioperative directions.

Question 17

A pregnant client in labor receives an epidural and anesthetic for pain control. The most important, initial nursing action is to?

Accepted Answer

Answer reason: Epidural anesthesia can cause sympathetic blockade leading to vasodilation and acute maternal hypotension, which may quickly reduce uteroplacental perfusion and fetal oxygenation. The earliest priority nursing action after initiation is close blood pressure surveillance (and readiness to intervene with positioning, IV fluids, and vasopressors per protocol) to prevent maternal-fetal compromise. Skin prep is important but occurs during preparation for insertion and does not address the most immediate post-administration physiologic risk. Consent should already be obtained by the provider before the procedure, and reassurance is not a safe priority compared with monitoring for a potentially rapid, high-impact complication.

Question 18

The nurse is planning care for the client experiencing dysphagia secondary to a CVA. Which intervention should be included in the plan of care?

Accepted Answer

Answer reason: Clients with post-stroke dysphagia are at high risk for aspiration and choking, so direct observation during eating is a key nursing safety intervention. Monitoring mealtime allows the nurse to assess swallowing ability, detect coughing/wet voice or pocketing, and promptly stop feeding and implement aspiration precautions if needed. Semi-Fowler positioning is often insufficient; best practice is upright positioning and tailored swallowing strategies based on observed tolerance. Oxygen during meals does not prevent aspiration, and physical therapy does not address swallowing as directly as nursing monitoring and potential referral to speech-language pathology.

Question 19

Which statement by the female client indicates that the client understands factors that may precipitate seizure activity?

Accepted Answer

Answer reason: Hormonal fluctuations can lower the seizure threshold in some clients, leading to catamenial epilepsy where seizures cluster around phases of the menstrual cycle. Recognizing menses as a trigger reflects accurate understanding of precipitating factors and supports planning for medication adherence and trigger management. Limiting dairy has no direct evidence-based link to provoking seizures in most patients. Contact sports relate more to injury risk and safety precautions than to physiologic precipitation of seizure activity, and contraception concerns are about drug interactions/teratogenic planning rather than a seizure trigger itself.

Question 20

A client experiences partial-thickness burns to both lower extremities and portions of the trunk. Which intravenous fluids should the nurse expect to administer to this client?

Accepted Answer

Answer reason: Major burns cause rapid capillary leak and large intravascular fluid losses, creating burn shock risk that requires prompt isotonic crystalloid resuscitation. LR is the preferred initial fluid in the first 24 hours because it expands intravascular volume effectively and its electrolyte composition is closer to plasma, supporting acid–base balance during massive resuscitation. D5W is hypotonic after metabolism and does not restore circulating volume adequately in acute burn shock. Potassium is typically avoided early because cell injury and acidosis can increase serum potassium, and colloids like albumin are generally introduced later (after capillary leak begins to resolve) rather than as first-line initial resuscitation.

Question 21

After reviewing morning laboratory data belonging to a trauma client, the nurse notices that the client’s potassium is 5.6 mEq/L. The nurse should immediately?

Accepted Answer

Answer reason: Hyperkalemia increases the risk of dangerous dysrhythmias, so the immediate nursing priority is rapid assessment for cardiopulmonary instability and early detection of ECG changes. Placing the client on continuous cardiac monitoring and checking vital signs provides real-time safety surveillance while further evaluation and treatment are arranged. Notifying the provider is appropriate, but it should follow immediate stabilization-focused assessment rather than delaying monitoring. Calling an emergency team or starting compressions is reserved for acute decompensation (e.g., unstable rhythm, cardiac arrest), which is not established by this lab value alone.

Question 22

A client arrives in the emergency department after a motor vehicle accident. The client has sinus tachycardia, is hypotensive, and has muffled heart sounds. There is no apparent sign of hemorrhage. Which condition does the nurse suspect?

Accepted Answer

Answer reason: Trauma can cause bleeding into the pericardial sac, raising intrapericardial pressure and restricting ventricular filling, which decreases stroke volume and leads to hypotension with compensatory tachycardia. Muffled heart sounds are a classic finding from fluid around the heart, and the absence of obvious external hemorrhage supports an obstructive shock etiology rather than hypovolemia. This presentation aligns with Beck’s triad (hypotension, muffled heart sounds, jugular venous distention, though JVD may not always be noted early). Pneumothorax more typically presents with acute respiratory distress and unilateral absent breath sounds, while pulmonary embolism is less directly suggested by muffled heart sounds in the immediate post-MVA setting.

Question 23

The nurse cares for a client diagnosed with atelectasis. Which intervention should be included in the client's plan of care?

Accepted Answer

Answer reason: Atelectasis is alveolar collapse, so the priority intervention is to promote sustained lung expansion and improve ventilation to reopen and prevent further collapse. Incentive spirometry encourages slow, deep inspirations with an inspiratory hold, which increases transpulmonary pressure and recruits collapsed alveoli more effectively than intermittent deep-breathing alone. Oxygen may improve hypoxemia but does not correct the underlying collapse and can delay recognition of worsening ventilation if used as the primary strategy. Ambulation supports ventilation and secretion clearance, but once-a-day frequency is insufficient compared with the regular, structured lung expansion achieved with hourly spirometry.

Question 24

The nurse cares for a client diagnosed with peptic ulcer disease. Which finding most likely explains the client’s peptic ulcer disease?

Accepted Answer

Answer reason: Regular NSAID use increases peptic ulcer risk by inhibiting COX enzymes, lowering protective gastric prostaglandins, and reducing mucus/bicarbonate production and mucosal blood flow. This weakens the gastric/duodenal lining and predisposes to erosions, ulceration, and GI bleeding, especially with chronic dosing. The other findings are not established primary causes of peptic ulcer disease; family cancer history and computer use are unrelated, and low vegetable intake is not a typical direct ulcer etiology. From a nursing risk-reduction perspective, identifying chronic NSAID exposure helps guide prevention (e.g., gastroprotection, alternative analgesics, monitoring for bleeding).

Question 25

The nurse cares for a client who experienced an endoscopic examination. Which is the least important nursing intervention post-endoscopy?

Accepted Answer

Answer reason: Post-endoscopy priorities focus on airway protection and early recognition of serious complications from sedation or procedural injury. Keeping the client NPO until the gag reflex returns reduces aspiration risk after topical anesthetics/sedation. Monitoring respirations and oxygen saturation is critical because hypoventilation and hypoxemia can occur after sedation. Observing for hematemesis helps detect bleeding or perforation-related injury. Routine intake and output monitoring is not typically a key immediate post-procedure safety intervention unless there are additional risks (e.g., dehydration, renal issues, large-volume IV fluids).

Question 26

A client is admitted to the emergency department with a diagnosis of sickle-cell crisis. The nurse anticipates which priority nursing intervention to be ordered by the physician?

Accepted Answer

Answer reason: Sickle-cell crisis involves vaso-occlusion and impaired oxygen delivery to tissues, so immediate measures that improve oxygenation help limit ongoing sickling and ischemia. Supplemental oxygen is a rapid, low-risk intervention that supports oxygen saturation while other definitive therapies (IV fluids, analgesia, possible transfusion) are arranged. Laboratory testing is important for assessment but does not treat the acute hypoxic/ischemic risk. Platelet transfusion is not a standard treatment for sickle-cell crisis and would not address the primary pathophysiology unless a separate thrombocytopenic bleeding problem exists.

Question 27

The nurse observes white patches and ulcerations in a client’s oral cavity. The client tells the nurse the sores developed during chemotherapy treatment even though the client performed oral care regularly. The nurse suspects which complication?

Accepted Answer

Answer reason: The described ulcerations with treatment timing strongly fit therapy-induced oral mucositis, a predictable complication of cytotoxic regimens. White patches can accompany mucosal sloughing and pseudomembranes within the inflamed tissue, so the overall pattern is more consistent with mucositis than an isolated fungal infection. Low hemoglobin does not directly cause oral ulcerations, and attributing this to poor oral hygiene is inconsistent with the client’s regular oral care and the classic chemo-associated onset.

Question 28

After a biopsy of the prostate, which symptom should a nurse instruct a client to report?

Accepted Answer

Answer reason: New inability to void or marked hesitancy suggests obstruction and requires prompt evaluation to prevent bladder overdistention and infection. Mild pain the next day and blood-tinged/discolored semen are common, expected after-effects and usually self-limited. A temperature threshold of 99°F is too low to reliably indicate infection; clinically concerning fever is typically higher and accompanied by systemic symptoms.

Question 29

A 16-year-old client had a full body cast applied 3 days ago. She’s diaphoretic, tachycardic, and tachypneic. Which condition is the client most likely experiencing?

Accepted Answer

Answer reason: Diaphoresis, tachycardia, and tachypnea can reflect severe pain and evolving shock physiology from ischemia, and this can occur within hours to days after casting. The highest-safety nursing priority is to suspect this complication because it requires urgent evaluation and cast splitting/bivalving to restore circulation. Anxiety could cause similar vital-sign changes, but in the setting of a recent full-body cast, a cast-related ischemic complication is the more dangerous and test-relevant diagnosis to rule out first.

Question 30

A nurse is giving discharge instructions to parents of a child who had a tonsillectomy. Which instruction would be most important to include?

Accepted Answer

Answer reason: After tonsillectomy, the key discharge priority is preventing secondary hemorrhage and protecting the surgical site while it heals. Using a straw creates negative pressure and suction in the oropharynx, which can dislodge clots/eschar and precipitate bleeding. This instruction directly reduces the risk of a potentially serious postoperative complication at home. In contrast, acidic fluids like orange juice can irritate the throat and increase discomfort, and salt-water rinses may traumatize tissue or provoke bleeding early post-op.

Question 31

At 6 cm of dilation, the client in labor receives a lumbar epidural for pain control. Which nursing diagnosis is most appropriate?

Accepted Answer

Answer reason: A perfusion-focused nursing diagnosis best captures the most clinically important and expected potential complication that requires ongoing monitoring and intervention (blood pressure trends, fetal heart rate, left uterine displacement, IV fluids/vasopressors per protocol). Acute pain “wearing off” is not the priority diagnosis immediately after initiation of an epidural and is not an expected immediate complication to manage first. Hyperthermia is not a typical direct effect of epidural anesthesia, and “risk for injury related to rapid delivery” is not the key problem introduced by administering an epidural at 6 cm.

Question 32

The nurse is preparing a client for cardiac catheterization. What is the priority nursing communication?

Accepted Answer

Answer reason:  Cardiac catheterization typically uses iodinated contrast, creating a key risk for an immediate hypersensitivity reaction and other acute complications that require prevention planning. Screening for a prior contrast-related allergy is a safety-critical assessment that drives premedication, alternative imaging/contrast choices, and emergency preparedness. While asking about prior experience may reduce anxiety, it does not mitigate a life-threatening procedural complication. The other statements are either inaccurate for standard prep (24-hour fasting) or misleading because most patients receive conscious/moderate sedation rather than being “put to sleep.”.

Question 33

The nurse is planning discharge instructions for the client going home on Coumadin (warfarin sodium). What is the priority teaching?

Accepted Answer

Answer reason: Warfarin increases bleeding risk by inhibiting vitamin K–dependent clotting factors, so preventing hemorrhage and recognizing early bleeding are the most safety-critical discharge priorities. Teaching should emphasize avoiding trauma (falls, contact sports, unsafe shaving) and promptly reporting bleeding signs such as gum bleeding, epistaxis, hematuria, melena, easy bruising, or prolonged bleeding from cuts. While consistent dosing time supports stable anticoagulation, it is secondary to immediate safety concerns about bleeding complications. The diet statement is inaccurate because the key interaction concern is consistent vitamin K intake (e.g., leafy greens), not specifically tomatoes and cucumbers.

Question 34

Which nursing action should be included in the plan of care to prevent an increase in intracranial pressure (ICP) in a comatose client with a closed head injury?

Accepted Answer

Answer reason: Maintaining cerebral venous drainage and minimizing impediments to blood outflow are key nursing strategies to help prevent secondary rises in intracranial pressure after head injury. Slight head-of-bed elevation promotes venous return from the brain and can reduce intracranial blood volume without compromising airway alignment. Routine hourly suctioning can trigger coughing and vagal stimulation, which can acutely raise intrathoracic pressure and thereby increase intracranial pressure. Turning the head to the side can kink neck vessels and obstruct venous drainage, and excessive environmental stimulation can provoke agitation and sympathetic surges that worsen intracranial pressure.

Question 35

An elderly client had recent surgery and is on bed rest. When planning care for the client, which nursing intervention is included in the care plan?

Accepted Answer

Answer reason: Active or assisted lower-extremity ROM promotes venous return via the calf muscle pump and helps reduce thromboembolic complications during bed rest. Daily wound checks are important but are more assessment-focused and do not directly address a major immobility complication as effectively as lower-extremity exercises. Hydrogen peroxide can be cytotoxic to granulation tissue, and prone positioning for pulmonary hygiene is not a routine or safe default postoperative intervention for many patients.

Question 36

A client who had his gallbladder removed 2 days ago now complains of pain in the right calf. Which nursing response has priority?

Accepted Answer

Answer reason: Postoperative unilateral calf pain raises concern for deep vein thrombosis, where the nurse’s immediate priority is rapid assessment for associated findings and escalation of care to prevent pulmonary embolism. Checking for swelling, warmth, redness, and comparing bilateral calf circumference helps identify a potential complication without increasing embolization risk. Interventions like massage are contraindicated because they may dislodge a thrombus. Warm compresses or exercises are not the first action before assessment and provider notification with appropriate precautions.

Question 37

The nurse is teaching a client with newly diagnosed diabetes mellitus about rotation of insulin injection sites. Which of the following is the correct information to give the client?

Accepted Answer

Answer reason: Insulin absorption varies by anatomic region (abdomen generally faster than thigh, buttock, or arm), so switching between regions can cause unpredictable onset and glucose variability. Rotating injections within the same general area (e.g., different spots across the abdomen) helps keep absorption more consistent while still preventing repeated trauma to one exact point. This practice also reduces the risk of lipohypertrophy, which can occur with repeated injections in the same spot and further disrupt absorption. Options stating that site rotation does not affect absorption or does not prevent lipohypertrophy are incorrect because both absorption rate and tissue changes are directly influenced by injection-site practices.

Question 38

A client who had intracavitary radiation treatment for cancer of the cervix 1 month earlier reports small amounts of vaginal bleeding. The nurse interprets this as which of the following?

Accepted Answer

Answer reason: Light spotting or small amounts of vaginal bleeding can occur in the weeks following intracavitary brachytherapy and is typically a treatment-related effect when not accompanied by heavy bleeding, foul discharge, or systemic symptoms. A rectovaginal fistula would more characteristically present with passage of stool or flatus via the vagina rather than isolated scant bleeding. Recurrence is possible but is less likely to present as mild spotting just one month post-treatment without other concerning findings; ongoing assessment is still warranted for worsening or persistent bleeding.

Question 39

A client is diagnosed with chronic renal failure and is told he must start hemodialysis. What is the most important client teaching for the nurse to provide?

Accepted Answer

Answer reason: Hemodialysis replaces critical kidney functions by removing excess fluid and clearing uremic toxins on a time-dependent schedule. Missing or shortening treatments rapidly increases risk for life-threatening complications such as hyperkalemia, pulmonary edema, severe uremia, and dysrhythmias. In contrast, a high-potassium diet is unsafe in renal failure because potassium excretion is impaired and levels can rise quickly between sessions. Dialysis also requires major lifestyle adjustments and skin care should generally avoid drying agents like alcohol due to pruritus and fragile skin in uremia.

Question 40

The nurse is obtaining a health history on a client. Which statement made by the client indicates a risk of renal calculi?

Accepted Answer

Answer reason: Renal calculi risk increases when urine becomes more concentrated and when stone-promoting solutes are higher or protective factors are lower. Cola beverages are commonly associated in nursing education with increased stone risk due to their phosphoric acid content and because they can displace water intake, promoting more concentrated urine. This history cue is a clearer kidney-stone risk factor than increased jogging, which only contributes if it leads to dehydration (not stated). Stress alone does not directly increase stone formation in the way dietary/fluids do.

Question 41

A client has just been admitted to the hospital after sustaining partialthickness burns to both lower extremities and portions of the trunk. The nurse is aware that the most important I.V. fluid to administer is?

Accepted Answer

Answer reason: Major burns cause rapid capillary leak and third spacing, leading to acute intravascular volume depletion and burn shock risk, so immediate priority is isotonic crystalloid resuscitation. This fluid best restores circulating volume and tissue perfusion without causing the intracellular water shifts associated with hypotonic solutions. D5W does not provide effective early volume expansion because the dextrose is rapidly metabolized, leaving free water. Colloids like albumin are typically deferred in the initial phase because they can extravasate through leaky capillaries and are not first-line for early burn resuscitation; potassium is avoided early due to hyperkalemia risk from cell injury and reduced renal perfusion.

Question 42

The nurse reviews symptoms of acute graft occlusion with the client who has had a revascularization graft procedure of the lower extremity. Which symptom of acute arterial occlusion stated by the client indicates the need for further teaching?

Accepted Answer

Answer reason: Severe pain, paresthesia, and inability to move the foot all align with worsening ischemia and possible threatened limb viability, requiring urgent evaluation. Warmth and redness at incision sites are more consistent with local inflammatory changes or possible wound infection rather than an acute loss of arterial blood flow. Misidentifying incision warmth/redness as a key sign of occlusion indicates incomplete understanding of ischemic complication warning signs.

Question 43

The nurse is caring for the surgical client during the first 24 hours after an abdominal-perineal resection. Which action should be priority?

Accepted Answer

Answer reason: After an abdominal-perineal resection, the perineal wound can bleed or drain significantly and may be less visible unless specifically inspected, so frequent assessment of the perineal dressing helps identify abnormal bleeding promptly. Colostomy output is often minimal or absent in the first 24 hours until bowel function returns, making it a less urgent indicator early on. Diet advancement and psychosocial support regarding viewing the stoma are important but are not the highest-priority actions in the first day after surgery.

Question 44

The client with Hodgkin’s lymphoma receives radiation treatments. The nurse should monitor the client for which specific symptoms of radiation pneumonitis?

Accepted Answer

Answer reason: The classic symptom pattern includes nonproductive cough and dyspnea, and it may be accompanied by low-grade fever due to inflammation. These findings reflect impaired gas exchange and alveolar-capillary irritation in the irradiated lung fields. Options emphasizing hypotension, altered mental status, or decreased urine output point more toward systemic shock, sepsis, or renal hypoperfusion rather than the typical presentation of radiation-induced lung toxicity.

Question 45

The nurse assesses the client diagnosed with acute myeloid leukemia. Which finding should be the nurse’s priority for implementing interventions?

Accepted Answer

Answer reason: New petechiae and ecchymoses are classic signs of low platelets and can precede mucosal, gastrointestinal, or intracranial hemorrhage, prompting urgent bleeding precautions and provider notification/lab evaluation. The low-grade temperature and mild tachycardia/tachypnea can be monitored but are not as immediately dangerous without evidence of infection or hemodynamic instability. Painful mucositis and fatigue require intervention, but they are typically less urgent than potential hemorrhage.

Question 46

The nurse is providing postoperative care for the client with a split-thickness skin graft on the burn wound at the sole of the right foot. Which is appropriate care for this client?

Accepted Answer

Answer reason: Keeping the grafted sole immobilized helps avoid graft displacement, hematoma/seroma formation under the graft, and failed “take.” Weight-bearing and frequent ambulation increase friction and pressure on the plantar surface, raising the risk of graft loss. A dependent position can worsen edema and venous congestion, which can impair perfusion and oxygen delivery to the healing graft.

Question 47

The nurse assesses that the client has some finger swelling of a newly casted right arm fracture with no other abnormal findings. Which is the nurse’s priority action?

Accepted Answer

Answer reason: Early mild swelling is expected after casting, and the priority is to prevent neurovascular compromise by reducing edema and maintaining perfusion. Elevating the extremity (ideally above heart level) promotes venous return, decreases swelling, and reduces pressure within the cast. There are no red-flag findings provided (e.g., severe pain, pallor, paresthesia, paralysis, or absent pulses) that would require urgent cast splitting or immediate provider notification. Documentation can be done after implementing the immediate measure that addresses the potential complication.

Question 48

A female client has an abdominal hysterectomy to remove a uterine fibroid. Which action should the nurse include when caring for the client postoperatively?

Accepted Answer

Answer reason: Postoperative care after hysterectomy prioritizes early detection of hemorrhage and abnormal vaginal drainage, which can occur even when the uterus is removed. Assessing the perineal pad provides a direct, ongoing indicator of vaginal bleeding and helps quantify blood loss and identify worsening trends quickly. Routine hormone replacement is not automatically indicated because ovarian function may be preserved and therapy depends on whether ovaries were removed and the patient’s risk profile. Prolonged bedrest increases thromboembolism risk, and advancing to a regular diet depends on return of bowel function rather than a fixed 6-hour time point after abdominal surgery.

Question 49

The nurse telephones the client 1 day post—cataract surgery. Which client statement necessitates an evaluation by an ophthalmologist?

Accepted Answer

Answer reason: New or worsening visual loss after cataract surgery is an abnormal finding that can signal serious complications such as increased intraocular pressure, retinal detachment, or endophthalmitis and requires urgent specialist assessment. Expected postoperative symptoms are mild discomfort, tearing, and gradually improving vision as the eye heals. A report of decreased vision compared with the prior day suggests deterioration rather than expected recovery and is a red-flag symptom. In contrast, decreasing redness is consistent with normal healing, and absence of swelling is not concerning. Pain that returns when analgesics wear off can be expected if mild and not associated with vision changes.

Question 50

The nurse is reviewing laboratory results of the client in labor prior to her receiving epidural anesthesia. Which result is most important to report to the HCP prior to the initiation of the epidural?

Accepted Answer

Answer reason: A platelet count at this level is borderline/low and may indicate impaired coagulation, prompting the provider/anesthesia to reassess safety, repeat labs, or choose an alternative pain management plan. The other values listed are not as immediately procedure-limiting for an epidural (mild anemia and normal glucose are typically not contraindications, and leukocytosis can be physiologic in labor). Because bleeding into the epidural space is a high-stakes complication, thrombocytopenia is the most critical finding to report before proceeding.

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

Potential for Complications NCLEX Practice Test

Continue Learning