Question 1

You're providing care to a 6 year old male patient who is receiving treatment for nephrotic syndrome. Which assessment finding below requires you to notify the physician immediately?

Accepted Answer

Answer reason: Nephrotic syndrome causes a hypercoagulable state; a warm, red, swollen leg suggests a possible DVT, an urgent complication that requires immediate provider notification. The other findings (frothy urine, proteinuria, hyperlipidemia) are expected features of nephrotic syndrome.

Question 2

The nurse is caring for a child after a tonsillectomy. The nurse monitors the child, knowing that which finding indicates the child is bleeding?

Accepted Answer

Answer reason: After tonsillectomy, continuous swallowing indicates the child is swallowing trickling blood from the surgical site, a classic early sign of hemorrhage. Bleeding typically causes tachycardia (not decreased pulse), discomfort is expected post-op, and BP changes are not the earliest indicator.

Question 3

After a tonsillectomy, the nurse reviews the health care provider's (HCP's) postoperative prescriptions. Which prescription should the nurse question?

Accepted Answer

Answer reason: Routine suctioning can traumatize the surgical site and precipitate hemorrhage after tonsillectomy; it should be avoided or done only gently and when necessary. The other orders are appropriate postoperative care.

Question 4

Six weeks after discharge, a client with a jejunoileal bypass for morbid obesity returns to the outpatient clinic reporting palpitations, abdominal cramps, diarrhea, and dizziness 30 minutes after meals. What complication should the nurse consider that the client is most likely experiencing?

Accepted Answer

Answer reason: Symptoms occurring about 30 minutes after meals—palpitations, cramping, diarrhea, dizziness—are classic for early dumping syndrome after bariatric/intestinal bypass due to rapid gastric emptying and fluid shifts.

Question 5

A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticipate that the client is at risk for which problem?

Accepted Answer

Answer reason: Persistently low urine output despite a fluid bolus with elevated BUN and creatinine indicates impaired renal function consistent with acute kidney injury rather than simple hypovolemia or infection.

Question 6

The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the priority nursing action?

Accepted Answer

Answer reason: Headache, nausea, and extreme restlessness after hemodialysis suggest dialysis disequilibrium syndrome with risk of cerebral edema and seizures. This is a potential emergency requiring immediate provider notification for specific interventions. Other options are supportive or unrelated.

Question 7

The nurse is teaching the client with polycythemia vera about prevention of complications of the disease. Which of the following statements by the client indicates a need for further teaching?

Accepted Answer

Answer reason: Clients with polycythemia vera should maintain adequate hydration (often >3 L/day) to decrease blood viscosity and prevent thrombosis. Fluid restriction to 500 mL/day is unsafe and reflects misunderstanding. Wearing support hose, checking blood pressure, and reporting edema are appropriate.

Question 8

A hemodialysis client with a left arm fistula is at risk for arterial steal syndrome. The nurse should assess for which manifestations of this complication?

Accepted Answer

Answer reason: Arterial steal syndrome diverts blood from the distal extremity after AV fistula creation, causing distal ischemia. Findings include hand pallor, pain, and diminished/weak pulse (often coolness and paresthesia as well), not warmth, ecchymosis, or edema.

Question 9

A client has just had surgery to create an ileostomy. The nurse assesses the client in the immediate postoperative period for which most frequent complication of this type of surgery?

Accepted Answer

Answer reason: Ileostomies produce high-volume liquid effluent rich in sodium and potassium; early postoperative patients are most at risk for dehydration and electrolyte losses.

Question 10

A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse elevates the limb, applies an ice bag, and administers an analgesic, with little relief. Which problem may be causing this pain?

Accepted Answer

Answer reason: Severe pain after casting unrelieved by elevation, ice, and analgesics indicates compromised circulation/compartment syndrome from the cast, i.e., impaired tissue perfusion. Infection would not occur immediately; anxiety or the recent fracture would be relieved at least partially by interventions.

Question 11

The nurse is admitting a client with Guillain-Barre syndrome to the nursing unit. The client has ascending paralysis to the level of the waist. Knowing the complications of the disorder, the nurse should bring which most essential items into the client's room?

Accepted Answer

Answer reason: Guillain-Barre can rapidly progress to respiratory failure and autonomic dysrhythmias. The most essential preparation is airway equipment for possible intubation and continuous cardiac monitoring.

Question 12

Nurses should encourage patients to cough and deep breathe after surgery to prevent atelectasis?

Accepted Answer

Answer reason: Deep breathing and coughing postoperatively promote lung expansion and mobilize secretions, preventing alveolar collapse (atelectasis).

Question 13

A patient is 6 hours post-op following hip replacement. Which finding is the most concerning?

Accepted Answer

Answer reason: Unilateral swelling and warmth suggest deep vein thrombosis after hip surgery, which can lead to a life-threatening pulmonary embolism and requires urgent action. The other findings (SpO2 95% on RA, expected surgical pain, and a small amount of blood on the dressing) are common early post-op findings.

Question 14

ETT cuff is underinflated. What’s the danger?

Accepted Answer

Answer reason: An underinflated endotracheal tube cuff fails to seal the trachea, allowing oropharyngeal or gastric secretions to leak past the cuff, increasing the risk of aspiration. Pneumothorax and bradycardia are unrelated, and hypoxia is less direct than aspiration risk.

Question 15

The patient has a platelet count of 60,000 cells/mm. Which measure in the care of this patient should the nurse implement?

Accepted Answer

Answer reason: Platelets 60,000 indicate thrombocytopenia with high bleeding risk. Tympanic temperature measurement avoids mucosal/skin trauma. The other options increase bleeding risk (razor shaving, vigorous skin care without lotions, firm-bristle toothbrush).

Question 16

A client who began using peritoneal dialysis a week ago was assessed by the nurse. Which finding on assessment is noted that would make the nurse suspect the onset of peritonitis?

Accepted Answer

Answer reason: Cloudy effluent from peritoneal dialysis is the hallmark early sign of peritonitis. Anorexia and mild discomfort are nonspecific, and 99°F is not a fever.

Question 17

In PACU, supplemental oxygen is given to a post-op patient because-?

Accepted Answer

Answer reason: Residual anesthetic agents in the alveoli can depress respirations and cause diffusion hypoxia; providing supplemental oxygen in PACU helps wash out anesthetic gases and prevent hypoxemia. The other options are either vague or not the primary reason.

Question 18

During haemodialysis, a patient tells the nurse he has a headache and feels nauseous. Which complication does the nurse suspect?

Accepted Answer

Answer reason: Headache and nausea during/after hemodialysis are classic signs of dialysis disequilibrium syndrome from rapid osmotic shifts; infection, air embolus, and acute hemolysis have different primary presentations.

Question 19

Which client is at greatest risk for complications following abdominal surgery?

Accepted Answer

Answer reason: Advanced age, obesity, and diabetes markedly increase postoperative risks such as poor wound healing and infection, making this client the highest risk among the options.

Question 20

A client with a fractured leg is exhibiting shortness of breath, pain upon deep breathing, and hemoptysis. The nurse would determine that these clinical manifestations are indicative of?

Accepted Answer

Answer reason: Fracture and immobility predispose to DVT; sudden dyspnea, pleuritic chest pain, and hemoptysis are classic signs of pulmonary embolus.

Question 21

The nurse is assessing a client who had a colon resection 2 days ago. The client states, "I feel like my stitches have burst loose." Upon further assessment, dehiscence of the wound is noted. The nurse should?

Accepted Answer

Answer reason: Wound dehiscence is a postoperative complication. The priority is to protect the wound by covering it with a sterile saline-moistened dressing and notify the surgeon. Prone positioning, atropine, or ACE wrapping are inappropriate and may worsen injury.

Question 22

The orthopedic nurse should be particularly alert for a fat embolus in which of the following clients having the greatest risk for this complication after a fracture?

Accepted Answer

Answer reason: Fat embolism risk is highest after long-bone fractures, especially the femur, and is common in young adults; thus the 21-year-old with a fractured femur is at greatest risk.

Question 23

The nurse is performing discharge teaching on a client with polycythemia vera. Which would be included in the teaching plan?

Accepted Answer

Answer reason: Polycythemia vera increases blood viscosity and places the client at high risk for thrombotic events. Discharge teaching should stress recognizing signs of thrombosis (e.g., calf pain/swelling, chest pain, neurologic deficits). Avoiding crowds relates to neutropenia, head-of-bed elevation is not specific to PV, and wearing socks/gloves is not a primary teaching point for thrombosis prevention.

Question 24

The nurse is caring for a client post-op femoral popliteal bypass graft. Which post-operative assessment finding would require immediate physician notification?

Accepted Answer

Answer reason: Loss of posterior tibial and dorsalis pedis pulses after a femoral-popliteal bypass indicates acute graft occlusion leading to impaired arterial perfusion and limb ischemia. This is a limb-threatening emergency requiring immediate surgeon notification. Expected early postoperative findings include mild edema, low-grade fever or redness, and serous drainage, which do not indicate acute vascular compromise.

Question 25

On the second post-operative day after a subtotal thyroidectomy, the client tells the nurse, "I feel numbness and my face is twitching." What is the nurse's best initial action?

Accepted Answer

Answer reason: Perioral numbness and facial twitching post-thyroidectomy suggest hypocalcemia from parathyroid injury, which can progress to laryngospasm. The priority is to promptly notify the provider for evaluation and treatment (e.g., IV calcium). Loosening the dressing or offering mouth care will not address this complication, and documenting only delays needed intervention.

Question 26

A client with adult respiratory distress syndrome has been placed on mechanical ventilation with PEEP. Which finding would indicate to the nurse that the client is experiencing the undesirable effect of an increase in airway and chest pressure?

Accepted Answer

Answer reason: Increased PEEP raises intrathoracic pressure, decreasing venous return and cardiac output, leading to hypotension. The BP drop indicates this complication. PO2 of 88 is acceptable, rales are not specific to increased pressure, and fewer spontaneous breaths are not the key adverse effect of high PEEP.

Question 27

Which of the following clients has the highest risk for pulmonary complications after surgery?

Accepted Answer

Answer reason: Upper abdominal surgery such as an open cholecystectomy most restricts diaphragmatic excursion and cough, increasing risk of atelectasis and pneumonia compared with orthopedic, lower abdominal, or spinal procedures.

Question 28

Which clinical manifestation during the actual bone marrow transplantation alerts you to the possibility of an adverse reaction?

Accepted Answer

Answer reason: Acute infusion reactions during bone marrow transplantation can present with respiratory compromise (dyspnea) indicating possible hypersensitivity or anaphylaxis. Fever, hematuria, or hypertension are less immediate indicators during the infusion.

Question 29

What is the immediate nursing priority for a client who has undergone a laryngectomy?

Accepted Answer

Answer reason: Immediately post-laryngectomy, airway patency is the priority. Edema and secretions can obstruct the tracheostomy, so keeping the trachea clear (suctioning, humidification) is most urgent. Infection monitoring, emotional support, and communication are important but not as immediate as airway maintenance.

Question 30

What is the initial treatment for a cerebrospinal fluid (CSF) leak after transsphenoidal hypophysectomy?

Accepted Answer

Answer reason: Initial management of a CSF leak after transsphenoidal surgery is conservative: strict bed rest with the head of bed elevated to lower intracranial pressure and allow the leak to seal. Reoperation or nasal repacking is reserved for persistent leaks; high-dose steroids are not a primary treatment.

Question 31

During an assessment, a nurse notes that the patient with diverticulitis has decreased bowel sounds; what does this finding indicate?

Accepted Answer

Answer reason: Hypoactive or decreased bowel sounds in a patient with diverticulitis suggest impaired intestinal motility, raising concern for bowel obstruction or paralytic ileus rather than normal function or recovery.

Question 32

In which of the following clients is rectal temperature most usually contraindicated?

Accepted Answer

Answer reason: Rectal temperature can stimulate the vagus nerve and precipitate bradycardia or dysrhythmias; this risk is significant after myocardial infarction. The other conditions are not typical contraindications for rectal temperature measurement.

Question 33

During the post-operative period, the LPN notes that the grafted area appears to be darker than the surrounding skin; what should be the LPN's immediate action?

Accepted Answer

Answer reason: A darker graft suggests compromised perfusion/venous congestion and potential graft failure; this is an urgent post-op complication that requires immediate provider notification rather than delay, documentation alone, or dressing application.

Question 34

Which nursing assessment should be reported to the physician for a client admitted following repair of fractured tibia with cast application?

Accepted Answer

Answer reason: Paresthesia indicates neurovascular compromise and is an early sign of compartment syndrome after casting; it requires immediate reporting. Warm toes are normal, pain can be expected early post cast unless unrelieved, and the pulse description is imprecise; the most critical finding is paresthesia.

Question 35

Which symptoms should the nurse assess in a patient with a permanent pacemaker who suspects battery malfunction?

Accepted Answer

Answer reason: Battery failure can cause decreased cardiac output and heart failure/bradycardia symptoms—dyspnea, dizziness, and peripheral edema—making C the best match. Other options reflect GI issues, respiratory disease, or acute MI.

Question 36

In a client with gastroesophageal reflux disease (GERD) who complains of chronic cough, which condition may this symptom indicate?

Accepted Answer

Answer reason: Chronic cough in GERD often results from microaspiration of acidic gastric contents into the airway, indicating aspiration risk.

Question 37

Which assessment finding indicates that a client with COPD may be experiencing oxygen toxicity?

Accepted Answer

Answer reason: High oxygen in COPD can depress ventilatory drive and cause CO2 retention; early signs of oxygen toxicity/hypercapnia are neurologic changes such as confusion and restlessness. The other options are not typical early indicators.

Question 38

During peritoneal dialysis, what does consistently blood-tinged solution draining from the abdomen indicate?

Accepted Answer

Answer reason: Peritoneal dialysate should be clear or straw-colored. Consistently blood-tinged effluent suggests ongoing intraperitoneal bleeding from vascular injury, not expected with a catheter, kidney damage, or rapid infusion.

Question 39

Which finding at the donor site after a skin graft indicates potential post-operative complications?

Accepted Answer

Answer reason: Purulent drainage indicates possible infection, a postoperative complication. Pink moisture and mild redness are expected; yellow crust can be normal dried exudate.

Question 40

Which of the following patients should receive antibiotic chemoprophylaxis against bacterial endocarditis during delivery?

Accepted Answer

Answer reason: Endocarditis prophylaxis at delivery is reserved for patients at highest risk of severe outcomes, notably those with prosthetic heart valves. Small ASD, MVP, cardiomyopathy, and WPW do not require prophylaxis.

Question 41

Which respiratory assessment finding would most concern the nurse after thoracentesis?

Accepted Answer

Answer reason: Post-thoracentesis, diminished/absent breath sounds on the affected side suggest a pneumothorax, an acute complication requiring urgent evaluation. The other findings are expected or unchanged.

Question 42

Which intervention should the nurse prioritize for a client with cirrhosis admitted with ascites and jaundice?

Accepted Answer

Answer reason: The priority is to monitor for hepatic encephalopathy, a life-threatening complication of cirrhosis due to ammonia accumulation. Diuretics and paracentesis are appropriate but not immediate priorities without specific indications; a high-protein diet may worsen encephalopathy.

Question 43

What is the most essential instruction for the nurse to give to the mother of a 9-month-old girl with a cast for talipes equinovarus?

Accepted Answer

Answer reason: Neurovascular compromise is the most serious early complication of a cast. Teaching the parent to monitor circulation (color, warmth, capillary refill, movement, sensation) is the priority instruction over comfort or routine visits.

Question 44

Which complication of cardiac catheterization should the nurse monitor for in the initial 24 hours after the procedure?

Accepted Answer

Answer reason: Hypotension within the first 24 hours may indicate bleeding/hematoma from the catheterization site or retroperitoneal hemorrhage, a serious early complication requiring prompt monitoring.

Question 45

Which postpartum client is most at risk for developing postpartum hemorrhage?

Accepted Answer

Answer reason: Delivering a macrosomic infant overdistends the uterus, predisposing to uterine atony, the leading cause of postpartum hemorrhage. Episiotomy and breast engorgement do not significantly increase risk for PPH, and fundal massage is a preventive intervention.

Question 46

After a tonsillectomy, which postoperative prescription should the nurse question?

Accepted Answer

Answer reason: Routine suctioning can traumatize the surgical site and precipitate hemorrhage after tonsillectomy; suction only if absolutely necessary. The other orders are appropriate for postoperative care.

Question 47

Which sign indicates a possible complication after abdominal surgery?

Accepted Answer

Answer reason: Absent bowel sounds suggest postoperative ileus or obstruction, a potential complication. The other findings indicate normal recovery or healing.

Question 48

What is the initial nursing care required for a client with cerebral vascular accident who has dysarthria?

Accepted Answer

Answer reason: Dysarthria after stroke can reflect bulbar muscle weakness and impaired swallowing, placing the client at high risk for airway compromise. The immediate priority is preventing aspiration.

Question 49

In the early postoperative period after bilateral adrenalectomy, if the client has an increased temperature, what should the nurse assess the client for?

Accepted Answer

Answer reason: Within the first 24–48 hours postoperatively, fever is most commonly due to atelectasis from inadequate lung expansion. Wound and urinary infections typically occur later.

Question 50

What equipment should the nurse keep at the bedside for a client who has undergone subtotal thyroidectomy in the first 48 hours after surgery?

Accepted Answer

Answer reason: In the first 24–48 hours after thyroidectomy, airway obstruction from edema or hematoma is a major risk. A tracheostomy set must be at the bedside to enable an emergency tracheotomy. The other options are not priority equipment for this complication.

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