Question 1

A client is admitted with a diagnosis of hydronephrosis secondary to calculi. The calculi have been removed, and postobstructive diuresis is occurring. What is the most important intervention by the nurse?

Accepted Answer

Answer reason: Postobstructive diuresis can cause rapid, high-volume urine losses that quickly lead to dangerous fluid and electrolyte derangements (especially sodium and potassium), predisposing the client to dysrhythmias, hypotension, and acute kidney injury. The priority nursing intervention is close surveillance for these complications so abnormalities can be corrected promptly with appropriate replacement and provider notification. While tracking urine output is important, doing it only “every shift” may miss rapid changes and does not directly detect life-threatening electrolyte shifts. Vital signs q8h and weighing every other day are too infrequent to provide early warning in this acute diuretic phase.

Question 2

The home health nurse assesses four clients. The nurse determines that which client is at highest risk for impaired wound healing after surgery?

Accepted Answer

Answer reason: Poorly controlled diabetes also decreases collagen synthesis and slows epithelialization, making postoperative incisions more prone to dehiscence and delayed closure. Advanced age adds additional risk, but the key differentiator here is uncontrolled glucose, which directly worsens healing physiology and infection susceptibility. In contrast, hypertension or mild overweight alone typically pose less direct impact on incision healing than chronic uncontrolled diabetes.

Question 3

The nurse is assessing a client with an abdominal incision and suspects there is a potential for delayed wound healing. Which assessment data that would validate this suspicion?

Accepted Answer

Answer reason: Thick, purulent drainage is a classic assessment finding of wound infection and suggests bacterial burden high enough to impede closure and collagen deposition. In contrast, dry intact sutures and closely approximated wound edges are expected findings of normal healing by primary intention. Sanguineous drainage in a collection device can be expected early post-op and is more consistent with bleeding than with delayed healing from infection.

Question 4

The nurse is caring for the client with a Zenker’s diverticulum. Which problem should be the nurse’s priority?

Accepted Answer

Answer reason: Zenker’s diverticulum traps food in a pharyngoesophageal pouch, which can later regurgitate—often when lying down—creating a high risk for airway compromise and aspiration pneumonia. Using priority frameworks (ABCs), protecting the airway takes precedence over discomfort or longer-term problems. Dysphagia-related malnutrition is important but is typically less immediately life-threatening than aspiration. Heartburn and constipation are not the most directly dangerous complications of this condition in the acute nursing priority setting.

Question 5

The HCP writes orders for the client who is 24 hours postvulvectomy. Which order should the nurse question?

Accepted Answer

Answer reason: Early postvulvectomy care prioritizes protecting the incision and minimizing perineal edema, bleeding, and tension on sutures. A high-Fowler’s position increases venous congestion and dependent swelling in the perineum and can place more pressure on the operative site, raising risk for wound dehiscence and impaired healing. More appropriate positioning is typically supine with limited hip flexion/abduction and gentle turning while maintaining perineal support. The other orders support routine wound hygiene, bowel management to reduce stool bulk/strain, and DVT prophylaxis without directly increasing perineal wound stress.

Question 6

The nurse notifies the HCP after feeling a pulsating mass during the vaginal examination of a newly admitted full-term pregnant client. Which HCP order should the nurse question?

Accepted Answer

Answer reason: A pulsating mass felt on vaginal exam suggests umbilical cord prolapse, an obstetric emergency with high risk of fetal hypoxia from cord compression. The immediate priority is to relieve pressure on the cord (eg, knee-chest positioning) and expedite delivery, often via cesarean section. Stimulating uterine contractions would worsen cord compression and decrease fetal oxygenation, making it unsafe in this context. A tocolytic may be used to reduce contractions temporarily while preparing for definitive delivery, which aligns with emergency management rather than augmentation.

Question 7

The nurse reviews the labor and delivery record of the 2-hour-old male newborn and sees this notation: “40 weeks’ gestation, large for gestational (LGA) age.” In response to this information, it is most important for the nurse to plan to assess the infant carefully for which condition?

Accepted Answer

Answer reason: A key immediate complication is clavicular fracture and brachial plexus injury, so assessing clavicles for crepitus, tenderness, asymmetry, or decreased arm movement is a priority safety check. This assessment targets a preventable missed injury that can affect neurovascular function and feeding/comfort. In contrast, acrocyanosis is commonly benign in early newborn transition and is not specifically increased by LGA status. Hypothermia risk is more characteristic of low birth weight or preterm infants rather than LGA.

Question 8

The nurse is managing the care of the infant with an unrepaired heart defect. Which recommendation should the nurse communicate to the parents?

Accepted Answer

Answer reason:  Infants with significant congenital heart disease are at higher risk for severe RSV infection and hospitalization, so prevention is a priority nursing teaching point. Palivizumab is recommended during RSV season for eligible high-risk infants to reduce RSV-related severe disease. Routine physical activity is generally encouraged as tolerated rather than broadly restricted, because unnecessary limitation can impair growth and development. Caloric restriction is inappropriate because infants with unrepaired heart defects often have increased metabolic demands and may struggle with weight gain, and standard immunizations should not be delayed as they reduce preventable infectious complications.

Question 9

The nurse is teaching the parents of the child with a history of hypoxemia. The nurse should instruct the parents to immediately notify the I-ICP if the child is experiencing which manifestation(s)?

Accepted Answer

Answer reason: Dehydration can decrease circulating volume and worsen tissue perfusion, increasing cardiopulmonary workload and exacerbating hypoxemia. Respiratory infections can quickly impair ventilation/oxygenation and may precipitate acute decompensation, making prompt provider notification critical. In contrast, weight changes and delayed milestones are important but typically represent longer-term issues that are less likely to require immediate notification than signs of acute illness affecting oxygenation.

Question 10

The infant is postoperative day 1 after emergency surgery for tracheoesophageal atresia. Which unsafe nursing action would require the intervention of the more experienced nurse?

Accepted Answer

Answer reason: Oral stimulation or anything that increases swallowing/sucking effort can increase tension at the surgical site and may worsen reflux/aspiration risk in the immediate postoperative period. Comfort measures should prioritize minimal esophageal stimulation while maintaining airway patency and prescribed decompression. By contrast, head-of-bed elevation and keeping the gastrostomy to gravity are common measures to reduce reflux and gastric distention that could stress the repair.

Question 11

The nurse is educating the parent of the child with vesicoureteral reflux. The therapeutic use of which treatment is important to include in the teaching?

Accepted Answer

Answer reason: Continuous low-dose antimicrobial prophylaxis is commonly taught to families to reduce UTIs while reflux is monitored for spontaneous resolution or managed surgically if needed. This teaching aligns with protecting kidney function by lowering the frequency of pyelonephritis episodes. Steroids, routine scheduled acetaminophen, and growth hormone do not treat the underlying reflux mechanism or meaningfully prevent infection-related renal damage.

Question 12

The nurse is assessing a client's response to skeletal traction applied to the lower extremity. Which finding would be considered to be normal?

Accepted Answer

Answer reason: A small amount of clear (serous) drainage with crusting can be an expected early pin-site finding as tissues respond to the foreign body and minor local irritation. In contrast, coolness and pallor distal to the fracture suggests impaired perfusion and possible compartment syndrome or vascular compromise. Marked erythema, swelling, purulent drainage, or increasing pain at the pin site would be more concerning for infection rather than a normal response.

Question 13

Which intervention describes an appropriate bladder program for a client in rehabilitation for a recent spinal cord injury?

Accepted Answer

Answer reason: Early bladder management after spinal cord injury focuses on preventing urinary retention and overdistention while minimizing catheter-associated infection risk. Clean intermittent catheterization on a frequent schedule helps keep bladder volumes low, reduces reflux/hydronephrosis risk, and supports a structured rehabilitation bladder program. An indwelling catheter increases risk for catheter-associated UTI and is generally avoided long-term unless specifically indicated. Credé maneuver can raise intravesical pressure and promote reflux/complications and is not a primary, preferred strategy for a new SCI rehabilitation program.

Question 14

A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which nursing intervention should be done first?

Accepted Answer

Answer reason: The priority nursing action is rapid escalation to the provider/trauma team so diagnostic confirmation and definitive management can be initiated promptly. Avoiding nasal suctioning or packing is critical because instrumentation can introduce infection or worsen the injury by forcing material intracranially. Positioning flat is not the first action and may increase intracranial pressure or aspiration risk if the patient vomits.

Question 15

A 46-year-old client with breast cancer complains of back pain and difficulty moving her legs. Which nursing intervention is the most appropriate?

Accepted Answer

Answer reason: New back pain with new lower-extremity weakness in a client with known breast cancer is a red-flag for metastatic spinal cord compression, a neurologic emergency requiring urgent evaluation and treatment to prevent permanent paralysis. The nurse’s priority is rapid escalation to the provider for immediate diagnostic workup and interventions (e.g., imaging, corticosteroids, potential radiation/surgery). Positioning changes or requesting PT delays definitive assessment and does not address the time-sensitive risk of cord ischemia. Providing only acetaminophen and reassurance is unsafe because it treats symptoms while missing a potentially irreversible complication.

Question 16

Which procedure or assessment must a nurse perform when preparing a client for eye surgery?

Accepted Answer

Answer reason: The nurse is responsible for confirming NPO status and communicating any violations promptly so anesthesia and the surgical plan can be adjusted safely. Eye surgery does not require routine eyelash clipping, and patching for 24 hours pre-op is not a standard universal requirement. While confirming that consent is signed is important, obtaining informed consent is the provider’s responsibility; the nurse’s must-do safety check here is verifying appropriate pre-op fasting.

Question 17

A hospitalized client has a central I.V. catheter inserted in the subclavian vein. Shortly after placement, the client develops shortness of breath and appears restless. The priority action by the nurse would be?

Accepted Answer

Answer reason: New-onset dyspnea and restlessness shortly after subclavian central line placement raises concern for an acute complication such as pneumothorax or hemothorax, which can rapidly impair ventilation. The priority nursing action is an immediate focused respiratory assessment to detect unilateral decreased or absent breath sounds that would support this life-threatening complication and prompt urgent escalation. Sedation or reassurance risks masking deterioration and delays recognition of an airway/breathing problem. Checking for medication is not time-critical compared with assessing and identifying a potentially emergent post-procedure complication.

Question 18

A nurse is assessing a child who has undergone complete repair of total anomalous pulmonary venous connection. The nurse is most concerned when the child experiences which of the following?

Accepted Answer

Answer reason: A drop in oxygen saturation is an early, objective sign of worsening gas exchange and potential cardiopulmonary decompensation that requires prompt assessment and intervention. In contrast, decreased work of breathing and increasing urine output generally suggest improving respiratory status and perfusion rather than deterioration. A decreasing respiratory rate may be benign (rest, improved distress) unless accompanied by hypoventilation signs, whereas falling saturation directly signals inadequate oxygen delivery.

Question 19

A nurse is preparing a child for discharge after being diagnosed with rheumatic fever without carditis. What instructions should the nurse give the parents?

Accepted Answer

Answer reason: Secondary prevention after rheumatic fever focuses on preventing recurrent group A streptococcal infections, which can trigger relapse and increase risk of future cardiac involvement. In a child without carditis, prophylaxis is still indicated and commonly emphasized around situations that can introduce bacteremia and streptococcal exposure, such as invasive dental procedures. A “1 month total” course is inadequate because prophylaxis is typically continued for years based on risk factors and presence/absence of carditis. Aspirin is used for arthritis/inflammation, but it is not a discharge instruction specifically targeted to managing chorea symptoms.

Question 20

When teaching parents about signs that indicate levothyroxine (Synthroid) overdose, which comment from a parent indicates the need for further teaching?

Accepted Answer

Answer reason: " Levothyroxine overdose produces hyperthyroid-like effects from excess thyroid hormone, increasing metabolic rate and sympathetic stimulation. Decreased sleep and restlessness are concerning signs in infants and should prompt assessment and provider notification rather than reassurance. The other statements appropriately identify common overdose indicators such as irritability, tachycardia awareness, and weight loss. Missing or minimizing sleep disturbance risks delaying recognition of toxicity and potential complications like persistent tachycardia and poor weight gain.

Question 21

The nurse asks the mother of a neonate at her 2-week office visit how the baby is doing. Which statement should the nurse be most concerned about?

Accepted Answer

Answer reason:  Persistent jaundice at 2 weeks can indicate pathologic hyperbilirubinemia (e.g., cholestasis/biliary obstruction, hemolysis, infection, or metabolic/endocrine disorders) and requires prompt assessment to prevent complications. The nurse should be concerned because prolonged jaundice warrants evaluation of bilirubin type (direct vs indirect) and overall feeding, hydration, weight gain, and stool/urine characteristics. By contrast, pulling legs up and crying after feeds can be consistent with common infant gas/colic and is less urgent if the infant is otherwise feeding and growing. Social engagement during feeds is an expected developmental finding at this age.

Question 22

A parent asks the nurse what criteria are used to measure good metabolic control in a child with diabetes mellitus. What is the best response by the nurse?

Accepted Answer

Answer reason: Having only infrequent mild hypoglycemic episodes suggests insulin dosing, nutrition, and activity are being balanced effectively without frequent overcorrection. By contrast, tolerating repeated severe hyperglycemia indicates poor control and increased risk for dehydration and ketoacidosis. A1C thresholds used for monitoring are far lower than 12% in good control, and poor growth is a sign of chronic inadequate control rather than a criterion for “good” control.

Question 23

The nurse is providing discharge instructions to the parents of a neonate who has undergone repair of a tracheoesophageal fistula and esophageal atresia. What is the most important information for the nurse to tell the parents?

Accepted Answer

Answer reason: After repair of tracheoesophageal fistula/esophageal atresia, the key ongoing risk at home is aspiration and respiratory compromise during/after feeds. Upright or semi-upright positioning with careful feeding techniques helps reduce reflux, coughing/choking, and aspiration while the surgical site heals and swallowing coordination matures. Teaching positioning is broadly applicable and safety-critical for every feeding, unlike antibiotics which may not be prescribed or are time-limited. Chest tube care is not a typical discharge priority for most infants after this repair, and “preventing crying” is not a primary complication-prevention strategy.

Question 24

The nurse is caring for a client with Reye’s syndrome who’s receiving pancuronium (Pavulon). What is the most important intervention for the nurse to include in the plan of care?

Accepted Answer

Answer reason: Loss of the blink reflex rapidly leads to corneal drying and abrasions, which are preventable complications that the nurse must proactively address. Lubricating drops/tears and eye care are therefore a high-priority nursing intervention while paralysis is in effect. Active ROM is not possible during pharmacologic paralysis and supine positioning can worsen aspiration risk rather than prevent a medication-related complication.

Question 25

The nurse is being observed by a group of student nurses while assessing a child in vaso-occlusive crisis. A student asks the nurse why she did not palpate the child’s abdomen. What is the most appropriate response by the nurse?

Accepted Answer

Answer reason: A markedly enlarged, congested spleen is more vulnerable to injury, so vigorous abdominal palpation can increase the chance of trauma and hemorrhage. The safest assessment approach prioritizes minimizing manipulation while monitoring for signs of splenic enlargement, anemia, and shock. Vomiting and generalized pain worsening may occur with illness, but they are not the key complication that drives avoiding abdominal palpation in this context.

Question 26

The parents of a child diagnosed with leukemia have stated that they'll give aspirin to their child for pain relief. What is the most appropriate response by the nurse?

Accepted Answer

Answer reason: Aspirin irreversibly inhibits platelet aggregation, increasing bleeding risk even when platelet counts are normal. Children with leukemia commonly develop thrombocytopenia from marrow suppression and chemotherapy, so any added platelet dysfunction can precipitate mucosal bleeding, bruising, or serious hemorrhage. The safest nursing guidance is to avoid aspirin/NSAIDs and use provider-recommended alternatives (often acetaminophen) while monitoring for bleeding. A common distractor is attributing the problem to reduced platelet production; aspirin impairs function rather than production.

Question 27

A nurse is working in her garden when a neighbor frantically comes over and states her child has been bitten by the new neighbor’s dog. What is the most important intervention by the nurse?

Accepted Answer

Answer reason: Immediate, thorough wound cleansing is the most effective first measure to reduce bacterial inoculum and lower the risk of infection after an animal bite. High-pressure irrigation and cleaning also decrease risk of complications while further assessment is arranged (depth, neurovascular status, tetanus status, and need for closure). Rabies post-exposure prophylaxis is determined by the animal’s vaccination status and ability to observe/quarantine, so it is not the first universal step at the scene. Empiric antibiotics may be indicated for high-risk bites (hands, deep punctures, immunocompromise), but they do not replace prompt irrigation, which is the priority action.

Question 28

Discharge instructions for a child with atopic dermatitis include keeping the fingernails cut short. Which rationale should the nurse give for this intervention?

Accepted Answer

Answer reason: Short fingernails reduce the depth of excoriations, lowering the risk of skin breakdown and bacterial superinfection (e.g., impetiginization) from introduced flora. This intervention targets prevention of a common complication rather than altering the underlying inflammatory condition. Nail-bed infection is not the primary risk addressed, and the condition is not “spread” by scratching.

Question 29

A child arrives in the emergency department 20 minutes after sustaining a major burn injury to 40% of his body. After initiating an I.V. line, which intervention should the nurse perform next?

Accepted Answer

Answer reason: Major burns (>20% TBSA) rapidly cause capillary leak and hypovolemic shock risk, so resuscitation must be guided by accurate end-organ perfusion measures. After IV access is established, the next priority is tight urine output monitoring because it is the most immediate, objective indicator of adequate fluid resuscitation in pediatric burn care. An indwelling urinary catheter enables hourly output measurement and early detection of under-resuscitation that could lead to acute kidney injury. Topical antimicrobials and wound/diagnostic steps are important but are secondary to stabilizing circulation and monitoring perfusion in the first hour of care.

Question 30

A child has just returned to his room with a cast on his leg after open reduction of a fractured femur. The nurse assesses the child and notes a 6 cm by 10 cm area of blood on the cast. What is the most important action for the nurse to take?

Accepted Answer

Answer reason: Postoperative bleeding can quickly progress to hypovolemia and shock, so the priority is to assess for systemic compromise using objective hemodynamic data. Vital signs (especially heart rate and blood pressure) help determine whether the visible cast bleeding is clinically significant and whether urgent escalation is needed. Marking drainage is appropriate for trending, but it does not evaluate current stability and delays identification of deterioration. The provider can be notified after immediate assessment data are obtained, unless the child is already unstable.

Question 31

Which instruction should the nurse include in the teaching plan for a 10- year-old child with a fracture of the radial bone?

Accepted Answer

Answer reason: A core principle of cast care teaching is early detection of complications such as skin breakdown and infection hidden beneath the cast. A foul odor suggests drainage, tissue maceration, or infection and requires prompt assessment and possible cast intervention to prevent worsening skin injury or osteomyelitis. Normal neurovascular findings (eg, brisk capillary refill) are expected and are not reportable problems. Warmth under a newly applied cast can occur as the cast cures, whereas concerning perfusion changes would be persistent pallor/coolness, numbness/tingling, increasing pain, or delayed capillary refill.

Question 32

A female client, age 15 months, has just had a hip-spica cast applied. Which nursing intervention is a priority for this client?

Accepted Answer

Answer reason: Neurovascular compromise is the most time-sensitive complication after cast application, and early detection prevents ischemia and permanent tissue/nerve injury. A hip-spica cast can increase pressure and swelling, so frequent checks of distal perfusion, movement, and sensation (e.g., color, warmth, cap refill, toe motion, pain/paresthesia) are a priority assessment. Limiting fluids is unsafe and increases dehydration/constipation risk rather than preventing cast wetness. Teaching and pain/constipation management are important but come after confirming the limb is neurovascularly intact.

Question 33

A 16-year-old male client was injured in a motorcycle accident and fractured his left tibia and fibula. He's in a long leg cast and complains of deep pain unrelieved by analgesics. The nurse suspects this client may be developing which condition?

Accepted Answer

Answer reason: Increased compartment pressure compromises capillary perfusion, leading to ischemia and escalating pain, often worsened by passive stretch. This is a limb-threatening complication requiring rapid assessment of neurovascular status and urgent intervention (e.g., loosening the cast and possible fasciotomy). Volkmann’s contracture is a late sequela of untreated ischemia, Dupuytren’s involves palmar fascia, and isolated peroneal nerve compression would more typically present with focal sensory/motor deficits rather than profound pain.

Question 34

A 10-year-old client with asthma has recently started receiving oral methylprednisolone. He begins to vomit and complains of his stomach hurting. Which nursing intervention is appropriate?

Accepted Answer

Answer reason: Place an I.V. and call the physician. Systemic corticosteroids can irritate the gastric mucosa and increase the risk of significant GI complications, and persistent vomiting can quickly lead to dehydration in a child. New onset abdominal pain with vomiting after starting this medication warrants prompt provider notification and supportive measures to prevent fluid deficit and to evaluate for gastritis or bleeding. Establishing IV access allows timely hydration and administration of antiemetics or other ordered therapies if oral intake is not tolerated. Decreasing the dose or doing nothing is outside nursing scope without an order and could delay assessment of a potentially serious adverse effect; drug “levels” are not a standard monitoring parameter for this medication in this context.

Question 35

The school nurse is providing an in-service program about dietary safety to all of the preschool teachers and aides who care for children younger than age 3. What is the most important information for the nurse to provide?

Accepted Answer

Answer reason: Young children are at high risk for choking due to small airway diameter, immature chewing, and limited ability to manage round, slippery foods. Whole grapes are a classic high-risk choking hazard because they can completely occlude the airway and conform to its shape. Cutting them into small pieces reduces the likelihood of complete obstruction and makes the food easier to chew and swallow safely. Cutting hotdogs only in half can still leave large, round segments; a safer approach is lengthwise into smaller strips, making this option less protective than addressing grapes directly. Limiting popcorn/peanuts is good general guidance, but the most critical teaching targets the common, high-fatality hazard of whole grapes in this age group.

Question 36

Five days after an exploratory laparotomy, the nurse assesses that the client has a distended abdomen, abdominal pain, absence of flatus, and absent bowel sounds. The nurse notifies the HCP concerned that the client could be experiencing which typical complication?

Accepted Answer

Answer reason: The classic findings are abdominal distension and pain with absent bowel sounds and failure to pass flatus or stool, which matches this assessment. This complication is expected to present in the days after laparotomy and requires prompt provider notification for evaluation and supportive management (e.g., bowel rest, NG decompression if needed, correction of electrolytes). In contrast, fluid volume excess would more typically produce edema, crackles, and hypertension rather than absent bowel sounds and obstipation.

Question 37

The nurse determines that all of the following must be completed for the client being prepared for surgery. Which intervention should the nurse complete first?

Accepted Answer

Answer reason: Give 10 mEq KCL IV for a serum potassium level Of 3.0 mEq/L Hypokalemia increases myocardial irritability and the risk of dysrhythmias, which can become life-threatening under anesthesia and perioperative stress. A potassium of 3.0 mEq/L is clinically significant and should be corrected/treated per orders before proceeding to less urgent preparation steps. Addressing this abnormal lab reduces immediate physiologic risk and helps prevent intraoperative complications. The checklist, vital signs, and removing jewelry are important for safety and documentation, but they do not mitigate an imminent cardiac/electrolyte complication the way potassium replacement does.

Question 38

The LPN reports to the nurse that the client’s TPN infusion was inadvertently turned off 1 hour ago. In response to this finding, which statement to the LPN should be the nurse’s priority?

Accepted Answer

Answer reason:  TPN contains a high dextrose concentration, so an abrupt interruption places the client at risk for an acute glucose abnormality, particularly hypoglycemia if endogenous insulin secretion has been stimulated. The safest immediate nursing priority is to assess the most likely and rapidly correctable complication with point-of-care testing. Changes in respiratory rate or blood pressure are less direct and less sensitive early indicators of a problem from a short TPN interruption. Level of consciousness can be affected by hypoglycemia, but checking glucose identifies the cause promptly and guides urgent treatment.

Question 39

Which client would the nurse identify as being least at risk for experiencing a CVA?

Accepted Answer

Answer reason: CVA risk rises with major vascular risk factors such as hypertension, obesity, smoking, diabetes, and estrogen-related thrombosis. A total cholesterol below 200 mg/dL is a favorable lipid profile and, by itself, does not add significant stroke risk compared with the other listed conditions. In contrast, essential hypertension is one of the strongest predictors of both ischemic and hemorrhagic stroke, and obesity is closely linked to atherosclerosis and metabolic syndrome. Oral contraceptives increase thrombotic risk, particularly in older women and those with additional risk factors, making that client more at risk than someone with a normal cholesterol level.

Question 40

The nurse cares for a client with a diagnosis of diabetes mellitus type 1 who is admitted to hospital for treatment of ketoacidosis. Which client behavior most likely contributed to the development of ketoacidosis?

Accepted Answer

Answer reason: DKA results from absolute insulin deficiency, leading to unchecked hepatic gluconeogenesis and lipolysis with ketone production and metabolic acidosis. Missing or inconsistent insulin dosing in type 1 diabetes is the most direct behavioral trigger for this pathophysiologic cascade. In contrast, taking too much insulin and exercising vigorously are more associated with hypoglycemia rather than ketosis. While not following sick-day rules can contribute (e.g., stopping insulin during illness), the core behavior most likely causing DKA is failing to administer insulin consistently.

Question 41

The nurse cares for a client following cardiac catheterization. The nurse assesses the insertion site and notices that the client is bleeding. What is the best action for the nurse to take?

Accepted Answer

Answer reason: Active bleeding at a post–cardiac catheterization access site is an immediate complication risk requiring prompt hemorrhage control. Direct manual pressure is the fastest, most effective first nursing intervention to reduce blood loss and prevent progression to hematoma, retroperitoneal bleeding (femoral), and shock. Sterile technique helps reduce infection risk while managing the site. Checking vital signs and distal pulses are important follow-up assessments, and the provider should be notified after initial bleeding control or if bleeding persists, but they do not take priority over stopping active bleeding.

Question 42

A client is to receive an intravenous injection of radiopaque dye for a diagnostic procedure. The nurse knows which action is most important to take before administering the dye?

Accepted Answer

Answer reason: IV radiopaque contrast can trigger hypersensitivity reactions ranging from urticaria to life-threatening anaphylaxis, so screening for prior contrast/iodine-related reactions is a critical safety step before administration. Identifying an allergy history allows the team to use alternative contrast, premedicate, or ensure immediate readiness for emergency treatment. Baseline vital signs and intake/output are useful but do not directly prevent the most acute complication associated with contrast injection. Height and weight are least relevant unless dosing is weight-based, which is not the primary safety concern here.

Question 43

The nurse admits a client to the hospital who was involved in a motor vehicle accident. The client sustained a skull fracture. The nurses knows this client is at risk for increased intracranial pressure and therefore avoids placing the client in which position?

Accepted Answer

Answer reason: Maintaining cerebral venous outflow is a key noninvasive measure to help limit rises in intracranial pressure. Turning the head laterally can kink/compress the jugular veins and impede venous drainage from the brain, which can worsen intracranial congestion and increase pressure. In contrast, elevating the head of bed 30–45 degrees and keeping the head midline supports venous return and helps reduce ICP when not contraindicated. A neutral neck alignment also avoids obstructing venous outflow and is typically preferred in clients at risk for increased ICP.

Question 44

A client with a spinal cord injury complains of severe headache. The nurse finds the client to be diaphoretic, hypertensive, and bradycardiac. The nurse suspects the client is experiencing autonomic dysreflexia. Which is the nurse’s first action?

Accepted Answer

Answer reason: Autonomic dysreflexia is an acute, life-threatening hypertensive crisis triggered by noxious stimuli below the level of spinal cord injury, creating severe vasoconstriction with reflex bradycardia and headache. The immediate priority is to lower blood pressure and reduce stroke risk, which is done by sitting the client upright to promote venous pooling and decrease cerebral perfusion pressure. Checking vital signs is important but does not treat the emergent hypertension and should occur while initiating this positioning intervention. After positioning, the nurse should promptly search for and remove the trigger (commonly bladder distension) and notify the provider if hypertension persists despite initial measures.

Question 45

The nurse cares for a client who recently underwent a colon resection. The nurse notes that arterial blood gas results show metabolic alkalosis. The nurse expects this finding because?

Accepted Answer

Answer reason: Metabolic alkalosis results from a primary increase in serum bicarbonate or a loss of hydrogen ions. Gastric suction removes hydrochloric acid from the stomach, causing loss of hydrogen and chloride and leading to a rise in bicarbonate (often with hypochloremia and possible hypokalemia). Hyperventilation is more consistent with respiratory alkalosis rather than a metabolic process, and severe pain typically drives hyperventilation and stress responses, not metabolic alkalosis. Normal saline maintenance fluids generally do not create metabolic alkalosis and may help correct chloride-responsive alkalosis.

Question 46

The nurse is teaching a 17-year-old client how to change a sterile dressing on the right leg. During the teaching session, the nurse notices redness, swelling, and induration at the wound site, interpreting these as suggesting?

Accepted Answer

Answer reason: Redness, swelling, and induration are classic local inflammatory findings that commonly indicate a developing wound infection, especially in the context of a recent or healing surgical/traumatic site. Induration reflects tissue edema and cellular infiltration that occurs with infectious/inflammatory processes. In contrast, dehiscence is separation of wound edges, hemorrhage presents with active bleeding or expanding hematoma, and evisceration involves protrusion of organs—none of which are described. Early recognition of these signs supports prompt assessment and intervention to prevent progression to systemic infection.

Question 47

A client undergoing peritoneal dialysis had 1000 mL of dialysate instilled. After the dwell time, only 500 mL has drained and the outflow has stopped. Which intervention should the nurse perform first?

Accepted Answer

Answer reason: A slowed or stopped peritoneal dialysis outflow is most commonly due to mechanical issues such as catheter tip malposition, kinking, or occlusion by omentum/constipation; simple repositioning can often restore gravity drainage quickly. Nursing actions should begin with least invasive troubleshooting to re-establish flow and reduce the risk of retained dialysate, discomfort, and inadequate ultrafiltration. Repositioning (turning side to side, sitting up, or ambulation if appropriate) can relieve transient obstruction without delaying care. Escalation to the provider is appropriate if basic measures fail or if there are signs of complications (e.g., severe pain, peritonitis, leakage), but it is not the first step when the likely cause is mechanical.

Question 48

A child with asthma uses a peak expiratory flowmeter in school. The results indicate his peak flow is in the yellow zone. Which intervention by the school nurse is appropriate?

Accepted Answer

Answer reason: Yellow-zone peak flow indicates worsening airway obstruction and increased risk for an exacerbation, which calls for prompt implementation of the child’s individualized asthma action plan (typically including a rescue bronchodilator and reassessment). Acting immediately per the prescribed plan helps reverse bronchospasm early and prevents progression to the red zone. Observation alone delays needed treatment and can allow respiratory status to deteriorate. Emergency transport is generally reserved for red-zone readings or severe symptoms (e.g., marked distress, cyanosis, poor response to rescue medication), which are not indicated by a yellow-zone result alone.

Question 49

A client returns to a nursing unit after a bronchoscopy and is expectorating pink-tinged mucus. Which action by the nurse is most appropriate?

Accepted Answer

Answer reason: After bronchoscopy, mild throat irritation and small amounts of blood-streaked/pink-tinged sputum can occur from minor mucosal trauma and is typically self-limited. The safest nursing response is to reassure while continuing focused monitoring for signs of significant bleeding or respiratory compromise (increasing hemoptysis, dyspnea, tachycardia, hypotension, decreasing SpO2). Immediate provider notification is reserved for abnormal findings such as frank bleeding, worsening respiratory status, or unstable vital signs. Assessments like auscultation and vitals are appropriate ongoing checks, but the priority is recognizing this as an expected finding unless it progresses.

Question 50

A child is intubated and placed on a ventilator after a near drowning. The physician’s order is to suction every 3 to 4 hours. The child’s parents ask the nurse why the suctioning is necessary. Which response by the nurse is the most accurate?

Accepted Answer

Answer reason: After near drowning, pulmonary irritation and increased secretions are common, raising the risk of plugging the endotracheal tube and causing hypoxia. Scheduled suctioning removes retained secretions to maintain ventilation and oxygenation and to prevent atelectasis from mucus obstruction. Infection prevention may be a secondary benefit, but suctioning is performed primarily to ensure airway patency rather than to prevent arrhythmias or correct fluid/electrolyte status.

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