Question 1

The full-term newborn is placed under phototherapy lights to treat hyperbilirubinemia. The nurse should assess the newborn for dehydration due to which effect of phototherapy?

Accepted Answer

Answer reason: Newborns are especially vulnerable because they have a large surface-area-to-body-mass ratio and immature fluid regulation. This can lead to dehydration manifested by weight loss, concentrated urine, decreased wet diapers, and dry mucous membranes. Decreased urine output is a possible consequence of dehydration, but it is not the primary mechanism caused by phototherapy.

Question 2

The nurse evaluates a preterm infant after a gavage feeding. The nurse determines that feeding intolerance has developed when which finding is noted during assessment?

Accepted Answer

Answer reason: Feeding intolerance in a preterm infant reflects impaired gastric emptying and intestinal dysmotility that can precede serious complications such as necrotizing enterocolitis. An increasing abdominal girth indicates abdominal distention from gas, delayed transit, or evolving bowel pathology and warrants holding feeds and further evaluation. In contrast, a zero gastric residual is a reassuring finding of good gastric emptying, not intolerance. Falling asleep after a gavage feeding can be normal for preterm infants and is not a specific sign of intolerance, and soft stools alone are nonspecific unless accompanied by other concerning findings.

Question 3

The nurse is caring for the pediatric client with congenital heart disease. The nurse should monitor the client for which specific complications?

Accepted Answer

Answer reason: Increased pulmonary blood flow or volume overload (e.g., left-to-right shunts) can precipitate congestive heart failure with tachypnea, poor feeding, and hepatomegaly. Decreased pulmonary blood flow or mixing lesions can cause hypoxemia, often reflected by low oxygen saturation and possible cyanosis. “Pulmonary hypotension” is not a typical expected complication terminology in CHD monitoring (pulmonary hypertension is), making options containing it less clinically accurate for surveillance priorities.

Question 4

The nurse is caring for the pediatric client immediately following a permanent pacemaker placement. Which nursing intervention is priority?

Accepted Answer

Answer reason: Immediate post–pacemaker insertion care prioritizes early detection of dysrhythmias and confirmation of effective pacing/capture to prevent hemodynamic compromise. Continuous ECG monitoring rapidly identifies loss of capture, sensing problems, new arrhythmias, or lead displacement that can occur soon after placement. Pain control and verifying prophylactic antibiotics are appropriate but do not address an immediate life-threatening complication first. A chest x-ray may be ordered to assess lead position and rule out pneumothorax, but continuous rhythm surveillance is the most time-sensitive intervention at the bedside.

Question 5

The nurse assesses that a neonate has meconium in the urine. Which describes the nurse’s best thinking about this assessment finding?

Accepted Answer

Answer reason: Meconium is stool and should not be present in urine; its presence suggests an abnormal communication allowing fecal material to enter the urinary system. This finding raises concern for a congenital fistula (e.g., enterovesical/rectourethral), which can lead to recurrent UTIs, sepsis risk, and requires prompt evaluation. Contamination from inadequate cleaning would more likely be meconium on the skin/diaper area rather than clearly identified within urine. Waiting to see if it appears again delays assessment of a potentially serious complication in a neonate.

Question 6

A nurse is planning discharge instructions for a client who is being treated for ventricular tachycardia. Which of the following rationales for including bananas in the client’s diet is most accurate?

Accepted Answer

Answer reason: Maintaining normal serum potassium is a key strategy to reduce ventricular irritability and dysrhythmia recurrence. Hypokalemia increases the risk of ventricular ectopy and ventricular tachycardia, and many cardiac patients are also on diuretics that can waste potassium. Bananas are a common dietary source of potassium, making them a practical discharge teaching point to support electrolyte stability. While sodium restriction may be relevant in hypertension/heart failure, it does not specifically address the electrolyte-related risk that contributes to ventricular tachydysrhythmias.

Question 7

The nurse is providing teaching for a client who experienced an acute episode of pulmonary edema. What is the most important instruction for the nurse to provide?

Accepted Answer

Answer reason: Call the physician if there is weight gain of more than 3 lb (1.5 kg) in 1 day. Acute pulmonary edema commonly reflects worsening left-sided heart failure with rapid fluid accumulation, so early recognition of fluid retention is the key safety teaching. A sudden weight increase is a sensitive, objective sign of volume overload and impending decompensation before severe dyspnea returns. Escalating care when weight rises rapidly helps prevent recurrence by prompting timely diuretic adjustment and evaluation. Routine weighing is helpful, but the highest-priority instruction is what threshold requires immediate provider notification to avoid another emergency.

Question 8

A nurse suspects a diagnosis of systemic lupus erythematosus (SLE). The nurse is most concerned when lab results identify?

Accepted Answer

Answer reason: SLE can cause immune-complex glomerulonephritis (lupus nephritis), and rising BUN/creatinine is a red-flag for kidney involvement that can progress to renal failure and require urgent evaluation and treatment. Leukocytosis may also suggest intercurrent infection, which is a major cause of morbidity in SLE and may be worsened by immunosuppressive therapy. In contrast, complement levels in active SLE typically decrease due to consumption rather than increase, making that finding less concerning for active disease. ANA elevation and cytopenias can occur in SLE but are not as immediately threatening as evidence of renal dysfunction.

Question 9

The nurse is providing information to a client diagnosed with systemic lupus erythematosus (SLE). The client asks the nurse if any type of blood dyscrasia may develop. What is the best response by the nurse?

Accepted Answer

Answer reason: Thrombocytopenia is a recognized manifestation and increases bleeding risk, so teaching should include that low platelets can occur and may require monitoring and treatment. Polycythemia is not typical of SLE and would suggest other etiologies such as chronic hypoxia or a myeloproliferative disorder. von Willebrand’s disease is usually an inherited bleeding disorder rather than a common dyscrasia that develops secondary to SLE.

Question 10

The community health nurse found an elderly female client lying in the snow. The client was unable to move the right leg because of a fracture. What action should the nurse take first?

Accepted Answer

Answer reason: Initial fracture first aid prioritizes preventing further tissue damage and neurovascular compromise by stabilizing the injured extremity. Immobilizing the limb as found limits movement that can worsen bleeding, increase pain, and convert a closed injury to an open one or damage vessels and nerves. Attempts to realign or reduce the fracture are not first-line nursing actions in the field and can cause additional harm without proper analgesia, imaging, and technique. Elevation may help swelling but is secondary to stabilization and can be difficult or unsafe before the extremity is properly splinted.

Question 11

The nurse suspects that a client with a recent fracture has developed compartment syndrome. The assessment of the client may find which symptom?

Accepted Answer

Answer reason: A key early and sensitive finding is severe pain that is out of proportion and worsens with passive stretch of the involved muscles. As ischemia progresses, motor function becomes impaired, leading to inability to perform active movement in the affected area. Findings like generalized bone loss or abnormal bony growth reflect chronic bone disorders rather than an acute post-fracture limb-threatening complication.

Question 12

A client has developed compartment syndrome following application of a cast from a fractured tibia. The nurse is aware that the priority goal of intervention is to?

Accepted Answer

Answer reason: Compartment syndrome is a limb-threatening emergency in which increased intracompartmental pressure compromises capillary perfusion, leading to ischemia and irreversible neuromuscular damage. The overriding goal is to restore circulation quickly to prevent ischemic necrosis, because prolonged hypoperfusion can cause permanent loss of function and may necessitate fasciotomy or amputation. Decreasing swelling and pain are important supportive outcomes, but they are secondary because they do not directly address the immediate risk of tissue ischemia. A more general goal like preventing complications is too nonspecific compared with the time-critical priority of preventing tissue death.

Question 13

A client with a left arm cast complains of a foul odor. What is the appropriate action by the nurse?

Accepted Answer

Answer reason: A foul odor from a cast is an abnormal finding that can signal skin breakdown, retained moisture, or wound infection beneath the cast, which requires prompt assessment. The nurse should inspect for drainage, fever, increasing pain, and hot spots on the cast, and notify the provider if infection is suspected because the area cannot be adequately visualized. Teaching hygiene is appropriate only after ruling out complications and does not address a potentially urgent problem. Neurovascular compromise is more typically suggested by the “5 Ps” (pain, pallor, pulselessness, paresthesia, paralysis) rather than odor alone.

Question 14

The nurse is aware that elevating a limb with a cast will prevent swelling. Which of the following actions best describes how this should be done?

Accepted Answer

Answer reason: Elevation reduces capillary hydrostatic pressure and promotes venous and lymphatic return, which helps limit edema after injury and casting. Keeping the extremity above the heart maximizes gravity-assisted drainage and is a standard measure to reduce swelling and pain and to lower risk of neurovascular compromise/compartment syndrome. Positioning only at heart level provides less edema control, and below heart level increases dependent pooling and swelling. This intervention supports ongoing cast-neurovascular monitoring by minimizing progressive tissue pressure within the enclosed cast.

Question 15

A client asks the nurse to explain the reason why a plaster cast cannot get wet. What would be the nurse’s best response?

Accepted Answer

Answer reason: Plaster casts lose structural integrity when exposed to moisture, which softens the plaster and compromises immobilization of the injured extremity. A weakened cast can crack, crumble, or deform, leading to inadequate stabilization and increased risk of delayed healing or reinjury. Moisture trapped in or under the cast can also contribute to skin breakdown, but the primary safety reason to avoid getting it wet is loss of cast strength. Using a hair dryer does not reliably restore cast rigidity and can create uneven drying or heat-related skin injury.

Question 16

Which nursing intervention would be appropriate for a client in traction?

Accepted Answer

Answer reason: Clients in skeletal traction are at high risk for local infection and skin breakdown at the pin insertion sites, so ongoing assessment is a key nursing responsibility to detect early redness, drainage, odor, increasing pain, or loosening. Early identification allows prompt cleansing per protocol and provider notification before osteomyelitis or systemic infection develops. Changing traction weights based on preference is unsafe because the prescribed force must be maintained continuously. Knots should not catch on pulleys and ROM should be performed to unaffected joints while protecting the immobilized fracture alignment, so a blanket instruction to ROM joints adjacent to the fracture every shift is inappropriate.

Question 17

Stool softeners would be given to a client prior to repair of a cerebral aneurysm for which reason?

Accepted Answer

Answer reason: Straining during defecation (Valsalva) elevates intrathoracic pressure, impedes venous return from the brain, and can transiently increase intracranial pressure. Stool softeners reduce the need to bear down, supporting stable neurologic and hemodynamic status before aneurysm repair. While Valsalva can cause vagal-mediated bradycardia, the primary peri-aneurysm safety concern is avoiding ICP spikes rather than treating heart-rate reflexes. Osmotic diuretics are not the main reason for preoperative stool softeners in this context.

Question 18

A nurse is planning care for a 33-year-old client who has just undergone a L4–L5 laminectomy. What is the most important intervention for the nurse to include?

Accepted Answer

Answer reason: Early, safe mobilization after lumbar spine surgery helps prevent key postoperative complications such as atelectasis, pneumonia, venous thromboembolism, ileus/constipation, and deconditioning. After an uncomplicated laminectomy, getting up on postoperative day 1 with assistance and proper body mechanics supports recovery without increasing risk when spinal precautions are followed. Prolonged bed rest and limiting repositioning increases respiratory and circulatory stasis and raises the risk of pressure injury. Measures like increased bracing in bed or changing mattress type do not address these major systemic risks as effectively as timely ambulation.

Question 19

A client is scheduled for chemonucleolysis with chymopapain to relieve the pain of a herniated disk. Which factor should be assessed before the procedure?

Accepted Answer

Answer reason: Products used as meat tenderizers may contain papain or related enzymes, so a history of reaction to these products suggests cross-sensitivity risk. Identifying this allergy beforehand helps prevent a potentially life-threatening complication and guides the team to avoid the agent or prepare for emergency management. In contrast, shellfish allergy is relevant to some iodine/contrast misconceptions and is not the key specific risk for this enzyme-based disk treatment.

Question 20

When discharging a client from the hospital after a laminectomy, the nurse recognizes that the client needs further teaching when he makes which statement?

Accepted Answer

Answer reason: Post-laminectomy discharge teaching emphasizes protecting the surgical site and preventing increased intrathecal pressure or strain on the spine to reduce risk of bleeding, re-injury, or neurologic compromise. Lifting heavy objects is typically restricted for several weeks, and picking up a 1-year-old child commonly exceeds safe weight limits and encourages twisting or flexion. In contrast, using proper body mechanics (bending knees) and sleeping on a firm mattress support spinal alignment and reduce strain. Driving restrictions for a few weeks are also commonly advised due to pain, limited mobility, and potential use of sedating analgesics.

Question 21

What is the most important information for a nurse to teach a client with chronic obstructive pulmonary disease?

Accepted Answer

Answer reason: Teaching warning signs (increased sputum volume or purulence, worsening dyspnea, fever/chills, increased cough, fatigue, decreased activity tolerance) supports timely provider contact and escalation of care. This is a high-yield complication-prevention priority because infections can rapidly worsen ventilation-perfusion mismatch and gas exchange. In contrast, independently deciding when oxygen needs changing is unsafe because oxygen should be titrated to ordered targets and over-oxygenation can worsen CO2 retention in some COPD clients. Monitoring pulse/respiratory rate is helpful but less specific and less protective than recognizing early infection and seeking care.

Question 22

A client with preexisting pulmonary disease has been diagnosed with lung cancer and is being evaluated for surgery. The nurse is aware that the impact of both conditions may?

Accepted Answer

Answer reason: Major lung resection requires adequate pulmonary reserve to tolerate one-lung ventilation and the postoperative reduction in functional lung capacity. Preexisting pulmonary disease (e.g., COPD, restrictive disease) can make predicted postoperative FEV1/DLCO unacceptably low, raising risk of respiratory failure, prolonged ventilation, and death. In such cases the patient may be deemed a poor surgical candidate and managed with nonsurgical modalities instead. The other options are not reliably true: pulmonary disease does not mandate pneumonectomy, does not necessarily prevent complete tumor resection, and certainly can affect surgical eligibility.

Question 23

Parents ask a nurse about their 8-year-old son’s activity level after cardiac surgery. Which would be the best response by the nurse?

Accepted Answer

Answer reason: Post–cardiac surgery teaching prioritizes gradual, individualized activity progression to prevent overexertion while supporting recovery and conditioning. A balanced rest-and-activity plan is broadly safe advice that fits most children regardless of the specific procedure and current tolerance, emphasizing pacing and monitoring for symptoms like fatigue, dyspnea, or chest pain. Statements implying no restrictions or very short, fixed timelines for return to school/activity can be unsafe because healing, pain control, and cardiopulmonary status vary. Narrow restrictions (e.g., “1 week”) are procedure- and provider-specific and typically longer for strenuous or contact activities, so a generalized fixed duration is not the best response.

Question 24

When counseling parents of a neonate with congenital hypothyroidism, the nurse should encourage which behavior?

Accepted Answer

Answer reason: Professional genetic counseling provides parents with informed discussion of possible etiologies, recurrence risk, and appropriate testing options, supporting safe decision-making for future pregnancies. Informal family history “retracing” is incomplete and can mislead families without expert interpretation of inheritance patterns. Alternative therapies are not a safe substitute for hormone replacement and can delay effective treatment, increasing risk of preventable complications.

Question 25

The nurse is reviewing assessment data of a client on fluid restriction for diabetes insipidus diagnostic testing. The nurse determines further intervention is necessary when the assessment identifies which finding?

Accepted Answer

Answer reason: A 3% to 5% weight loss over a short period is a clinically significant marker of acute volume depletion and indicates the restriction is causing or worsening hypovolemia, requiring prompt intervention (e.g., reassessment of orders, vital signs, and hydration status). In contrast, a modest weight gain would be more consistent with improved water retention or overhydration rather than dehydration. Ongoing polyuria is expected in suspected diabetes insipidus and, by itself, is less specific than acute weight loss for identifying a developing complication from restriction.

Question 26

The nurse is assessing a child acutely ill with Reye’s syndrome. Which assessment change would the nurse be most concerned about?

Accepted Answer

Answer reason: The combination of hypertension with bradycardia reflects Cushing’s response, a late and ominous indicator of increased intracranial pressure with threatened brainstem perfusion. This pattern is more concerning than isolated irritability because it signals a progressing, potentially life-threatening complication requiring immediate escalation of care. Hypotension with tachycardia suggests shock physiology, but it is not the classic high-risk pattern for worsening intracranial pressure in this context.

Question 27

The parents of a child with sickle cell anemia ask the nurse what would be a priority factor in the prevention of infection for their child. What is the most appropriate response by the nurse?

Accepted Answer

Answer reason: Prompt medical assessment when the child is sick supports rapid cultures, early antibiotic therapy when indicated, and close monitoring for sepsis and other complications. Nutrition and reducing stress can support general health but do not address the urgent need for early detection and treatment of infection in this high-risk population. Avoiding strenuous exertion relates more to preventing hypoxia-triggered vaso-occlusive episodes than to primary infection prevention.

Question 28

The nurse is teaching parents of a hemophilic child about the immediate treatment for bleeding. The nurse determines that teaching has been effective when the parents make which statement?

Accepted Answer

Answer reason: Immediate bleeding management in hemophilia emphasizes controlling bleeding while minimizing further tissue trauma and joint damage. Immobilizing the involved part reduces movement-related disruption of forming clots and helps prevent expansion of bleeding into soft tissue or joints. Elevation decreases hydrostatic pressure and can reduce ongoing bleeding and swelling. Heat is avoided early because it promotes vasodilation, and withholding factor replacement is unsafe because factor administration is key to achieving hemostasis; direct pressure may help with superficial bleeding but does not address the high risk of deeper muscle/joint hemorrhage that immobilization and elevation target.

Question 29

A child with idiopathic thrombocytopenic purpura is admitted to the hospital with a platelet count of 20,000/µl. The nurse is aware that the child should be closely monitored for which condition?

Accepted Answer

Answer reason: A sudden or progressive neurologic change is an early, high-priority indicator of possible CNS bleeding that requires immediate assessment and rapid escalation of care. With platelets around 20,000/µL, monitoring for subtle mental status changes is more safety-critical than monitoring for non-bleeding-related findings. Options like proteinuria or hand-foot syndrome are not characteristic complications of idiopathic thrombocytopenic purpura and do not reflect the primary life-threatening risk.

Question 30

A mother is concerned because her child was exposed to varicella in day care. Which statement by the nurse would be the most accurate?

Accepted Answer

Answer reason: Varicella is primarily spread by respiratory droplets and direct contact with vesicular fluid, and infectivity continues until lesions have dried and formed crusts. This guidance helps families determine when isolation can end and when it is safer to return to school/day care, reducing transmission risk. The rash of varicella is classically vesicular in “crops,” making the nonvesicular statement inaccurate. Aspirin is contraindicated in children with viral illnesses due to the risk of Reye syndrome, and the incubation period is typically about 10–21 days rather than 5–10 days.

Question 31

Which observation by a nurse indicates that the parent of a neonate with developmental dysplasia of the hip understands the discharge teaching?

Accepted Answer

Answer reason: Developmental dysplasia of the hip requires maintaining the hips in abduction and flexion to promote proper positioning of the femoral head in the acetabulum and reduce worsening instability. Using multiple diapers is a commonly taught (though less effective than prescribed orthoses) home measure intended to keep the hips abducted when caring for the infant. Tight swaddling tends to force hip extension/adduction, which increases risk of worsening dysplasia and undermines treatment goals. Prone sleeping is unsafe for infants due to increased risk of sudden infant death syndrome, indicating poor understanding of safe discharge teaching.

Question 32

A 12-year-old child diagnosed with muscular dystrophy is hospitalized secondary to a fall. Surgery is necessary as well as skeletal traction. Which complication should be of greatest concern to the nursing staff?

Accepted Answer

Answer reason: This makes respiratory compromise a higher-priority, potentially life-threatening complication compared with localized issues. Pin-site infection and skin breakdown are important but are usually more gradually developing and easier to detect early with routine assessment and care. Nonunion can occur, but it is not typically the most immediate threat to airway and breathing in this population.

Question 33

A child is diagnosed with right chronic otitis media. After the child returns from surgery for myringotomy and placement of ear tubes, which intervention is appropriate?

Accepted Answer

Answer reason: Postoperative care after myringotomy with tympanostomy tubes prioritizes promoting drainage and preventing aspiration of secretions. Placing the child on the operative side allows blood/serous drainage to flow out of the external ear rather than pooling in the pharynx, reducing nausea and risk of airway contamination. This position also helps the nurse assess ongoing otorrhea, which can be expected initially. Positioning on the nonoperative side can impede dependent drainage from the operated ear and increase discomfort or swallowing of secretions.

Question 34

Which statement by the parent of a 4-year-old boy who just had a tonsillectomy indicates that a nurse’s discharge instruction has been successful?

Accepted Answer

Answer reason:  After a tonsillectomy, the priority is maintaining a patent airway and reducing aspiration risk from blood-tinged secretions or emesis. Prone or side-lying positioning allows secretions to drain out of the mouth rather than pooling in the pharynx where they could be swallowed or aspirated. Supine positioning, especially flat or with a pillow, increases the chance of obstructed drainage and unrecognized bleeding. This parent statement reflects correct understanding of post-op positioning to prevent respiratory compromise and aspiration.

Question 35

What is the treatment team’s priority in planning the care of a client with an eating disorder?

Accepted Answer

Answer reason: Daily weights and frequent vital signs provide objective trend data to identify bradycardia, hypotension/orthostasis, hypothermia, and unsafe weight loss or inadequate gain early. This surveillance guides timely escalation of care (e.g., labs, cardiac monitoring, higher level of treatment) before complications such as dysrhythmias occur. Interventions like restricting exercise or prescribing bed rest may be used selectively, but they are not the universal, highest-priority planning focus compared with monitoring for acute medical compromise.

Question 36

A client with gestational diabetes has just delivered a 10-lb, 2-oz neonate at 39 weeks’ gestation. Which priority nursing intervention should be included in the care plan?

Accepted Answer

Answer reason: Infants of diabetic mothers—especially macrosomic newborns—are at high risk for early neonatal hypoglycemia due to fetal hyperinsulinemia after placental glucose supply is abruptly removed at birth. This complication can be rapid and clinically silent initially, so immediate screening and ongoing monitoring are a priority to prevent neurologic injury and seizures. Bilirubin assessment is relevant later for jaundice risk, but it is not as immediate a threat as hypoglycemia in the first hours of life. Administering insulin is not routine and could worsen hypoglycemia; management typically focuses on early feeding and/or IV dextrose if low glucose is confirmed.

Question 37

A client has a chest tube placed for treatment of a pneumothorax. Which statement indicates the chest tube is ready to be removed?

Accepted Answer

Answer reason: Readiness for chest-tube removal in pneumothorax is best indicated by resolution of the pleural air leak and lung re-expansion, which is assessed through the chest drainage system’s function. Lack of tidaling (fluctuation) in the water-seal chamber after suction is discontinued suggests intrapleural pressure changes have normalized and the lung is no longer leaking air. Symptom improvement and normal ABGs can occur even with a small persistent air leak or incomplete re-expansion, so they are not the most reliable removal criteria. Serous drainage describes fluid character but does not confirm the pneumothorax has fully resolved.

Question 38

The nurse is discharging a client who is diagnosed with gout. The nurse recognizes further teaching is necessary when the client states?

Accepted Answer

Answer reason: Adequate hydration helps dilute urine and promotes renal excretion of uric acid, reducing the risk of uric acid kidney stones and supporting gout management. Limiting fluids can worsen hyperuricemia-related complications and increase the likelihood of nephrolithiasis, making this statement incorrect and indicating a teaching need. Dietary purine reduction (e.g., limiting red meat like beef) is appropriate education because purines increase uric acid production. Weight reduction can decrease gout flares, and urate-lowering therapy is used to reduce uric acid levels, so those statements reflect correct understanding.

Question 39

The nurse cares for a client with cervical cancer when the nurse notices the radium implant has been dislodged. Which action should the nurse take first?

Accepted Answer

Answer reason: A dislodged brachytherapy source is an immediate radiation exposure hazard, so the priority is to minimize time of exposure, maximize distance, and use shielding. Using long-handled forceps increases distance from the source and placing it into a lead container provides prompt shielding to reduce exposure to staff and others. Wrapping it in a blanket is not an appropriate radiation-shielding measure and can increase contamination/handling time. After the source is secured, the nurse should then notify the radiation safety/radiology team and the provider per facility protocol.

Question 40

The nurse inserts an indwelling urinary catheter in a client. Which nursing intervention is most likely to prevent a urinary tract infection?

Accepted Answer

Answer reason: Catheter-associated UTI risk is reduced by limiting bacterial colonization at the urethral meatus and maintaining a clean, closed drainage system. Routine perineal/meatal hygiene decreases microbial burden where organisms commonly ascend along the catheter. In contrast, disconnecting tubing breaks the closed system and increases contamination and infection risk. Routine irrigation is not recommended unless specifically indicated (e.g., obstruction) because it can introduce organisms and traumatize mucosa; restricting fluids concentrates urine and reduces flushing, which can also increase infection risk.

Question 41

A client develops stomatitis status postchemotherapeutic treatment. Which nursing action is most appropriate to reduce pain and irritation in the mouth?

Accepted Answer

Answer reason: Oral mucositis after chemotherapy causes fragile, ulcerated mucosa that is easily traumatized and highly painful, so nursing care should minimize additional irritation and infection risk. Using oral temperature probes can abrade lesions and introduce microorganisms, increasing discomfort and the likelihood of complications in an immunocompromised client. Gentle oral care is important, but frequent toothbrushing can worsen pain if bristles irritate inflamed tissue, and peroxide rinses can be drying/irritating if not specifically ordered in an appropriate dilution. Hot liquids typically exacerbate burning and tissue irritation, so they are avoided in favor of cool/tepid options.

Question 42

The nurse cares for a client post-thyroidectomy. The nurse notices the client experiences muscle twitches. Upon questioning, the client complains of numbness and tingling of the mouth and fingertips. The nurse suspects which electrolyte disturbance?

Accepted Answer

Answer reason: After thyroidectomy, inadvertent removal or ischemia of the parathyroid glands can cause decreased PTH and an acute drop in serum calcium. Low calcium increases neuromuscular excitability, producing perioral/fingertip paresthesias and muscle twitching (early tetany), often preceding classic Trousseau/Chvostek signs. This postoperative pattern is far more characteristic of calcium imbalance than sodium or potassium disturbances. Hypermagnesemia typically causes hyporeflexia, lethargy, and muscle weakness rather than twitching and tingling.

Question 43

The nurse provides teaching to a client who is status post-laminectomy with fusion. The nurse understands further teaching is necessary when the client states?

Accepted Answer

Answer reason: After a laminectomy with fusion, spinal alignment must be maintained to protect the surgical site and promote proper fusion. Prone positioning increases lumbar lordosis and can place stress on the incision, hardware, and fused segments, raising pain and complication risk. Safer teaching typically emphasizes supine or side-lying with the spine in neutral and use of log-rolling to avoid twisting. The other statements align with standard post-fusion precautions: maintain upright posture, engage in gentle activity while avoiding heavy/strenuous exertion, and avoid prolonged static positions that increase stiffness and discomfort.

Question 44

The nurse cares for a client who recently underwent surgery to create a stoma for colostomy. The nurse notes that the stoma is dark and dusky in color. What action should the nurse immediately take?

Accepted Answer

Answer reason: A new stoma should be pink to red and moist; a dark, dusky appearance suggests compromised perfusion/ischemia and potential necrosis, which is an urgent postoperative complication. This requires immediate escalation for prompt evaluation and possible intervention to restore blood flow or revise the stoma. Bag changes or removal do not address the underlying perfusion problem and can delay definitive care. Irrigation is not an immediate postoperative action and could worsen tissue injury or obscure assessment findings.

Question 45

The nurse cares for a client recovering from a subdural hematoma. Which nursing intervention should the nurse perform to prevent foot drop and contractures?

Accepted Answer

Answer reason: Foot drop and contractures result from prolonged immobility and loss of normal ankle dorsiflexion positioning, so prevention focuses on maintaining the foot in functional alignment and providing consistent support. High-top sneakers help hold the ankle in a more neutral position during rest and limited mobility, reducing plantarflexion and minimizing the risk of Achilles tendon shortening. LMWH and SCDs are aimed at preventing venous thromboembolism, not musculoskeletal deformities. While ambulation helps overall mobility, it may not be feasible early after a subdural hematoma and does not provide continuous ankle positioning support when the client is in bed.

Question 46

The nurse is caring for a client who has been admitted with suspected placenta previa. After assessing vital signs and applying an external monitor, what is the most important action by the nurse?

Accepted Answer

Answer reason: Obtain blood work and start I.V. catheters. Placenta previa places the client at high risk for sudden, significant antepartum hemorrhage, so the priority is anticipating and preparing for rapid deterioration. Establishing large-bore IV access and obtaining labs (e.g., CBC, type and screen/crossmatch, coagulation studies per protocol) supports immediate fluid/blood replacement and readiness for emergent intervention. Urinary catheterization may be helpful for monitoring output but is secondary to securing vascular access and blood availability. Immediate cesarean delivery is not automatically indicated without assessing bleeding severity and maternal-fetal stability, but preparation for hemorrhage is always time-critical.

Question 47

A 72-year-old client is being discharged from outpatient surgery after having a cataract removed from his right eye. Prior to discharging the client, it is most important for the nurse to teach the client to?

Accepted Answer

Answer reason: After cataract extraction, preventing increased intraocular pressure and protecting the operative site are top priorities to reduce risk of wound dehiscence, hemorrhage, and infection. Avoiding rubbing or any pressure directly protects the surgical incision and implanted lens position during the vulnerable immediate postoperative period. The other options either give unsafe permission to resume normal activity without restrictions or provide incorrect/less critical timing and instructions compared with protecting the eye from mechanical trauma. Teaching this precaution is a key discharge safety intervention to prevent vision-threatening complications.

Question 48

Immediately after a client’s cardiac catheterization via the femoral artery, the client is being assessed by the nurse. Which assessment finding would the nurse report immediately to the physician?

Accepted Answer

Answer reason: A newly absent distal pulse suggests arterial occlusion, thrombosis, embolus, or severe spasm at/near the access site and can rapidly progress to limb ischemia, making it an urgent complication to report. In contrast, a heart rate of 98 bpm and a blood pressure of 105/70 mm Hg can be within acceptable post-procedure ranges if the client is otherwise stable. A small, dime-sized amount of drainage can occur at the puncture site and is monitored, whereas loss of distal perfusion requires immediate provider evaluation and intervention.

Question 49

The nurse is providing education for a client diagnosed with Cushing’s disease. Which statement indicates that he understands his disease?

Accepted Answer

Answer reason:  Cushing’s disease involves chronic excess cortisol, which promotes sodium and water retention and increases risk for fluid overload, edema, and hypertension. Daily weights are a sensitive, practical way to detect early fluid retention and worsening volume status before more obvious symptoms appear. Reporting weight gain promptly supports timely adjustment of therapy and reduces complications such as worsening blood pressure or heart strain. In contrast, suggesting increased sodium intake is unsafe because it can further exacerbate fluid retention and hypertension.

Question 50

The nurse is assessing a client who has undergone a radical cystectomy and ileal conduit for the treatment of bladder cancer. The nurse is aware that immediate intervention is necessary when the client presents with which finding?

Accepted Answer

Answer reason: A dusky appearance suggests compromised circulation and possible ischemia/necrosis at the stoma, which can quickly progress to tissue loss and conduit failure. This finding warrants urgent assessment and rapid notification of the surgical team because timely intervention may be needed to restore perfusion. In contrast, a red, moist stoma and slight oozing with appliance changes can be expected due to the stoma’s vascularity, and urine output >30 mL/hr is generally reassuring for renal perfusion.

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