Question 1

A postoperative client who is at risk for evisceration has returned to the unit after an abdominal hysterectomy. The nurse would assess the client for which of the following?

Accepted Answer

Answer reason: Increasing serosanguineous output from the incision and a low-grade fever can indicate impaired wound healing or early infection, both of which raise the risk of dehiscence progressing to evisceration. The nurse’s priority assessment for impending wound failure focuses on local incision changes (drainage, separation, tissue integrity) rather than isolated systemic shock signs. Tachycardia, hypotension, and decreased LOC are more consistent with hypovolemia/hemorrhage or other systemic deterioration and are less specific early warning findings for evisceration.

Question 2

A nurse enters the room of a client who had a left modified mastectomy 8 hours earlier. Which assessment indicates that the nursing assistant assigned to the client needs further instruction and guidance?

Accepted Answer

Answer reason: Post-mastectomy care focuses on preventing impaired lymph drainage and reducing risk of lymphedema by avoiding constriction or trauma to the affected arm. Elastic cuffs can create a tourniquet-like effect that increases venous/lymphatic congestion and swelling, especially early after surgery. In contrast, elevating the affected arm and performing gentle hand/arm exercises (like ball squeezing as ordered) help promote lymphatic flow and reduce edema. Using a blood pressure cuff on the non-affected arm is appropriate because the operative-side arm should be protected from procedures that increase pressure or cause injury.

Question 3

A client has just received a renal transplant and has started cyclosporine therapy to prevent graft rejection. What is the most important information for the nurse to tell the client?

Accepted Answer

Answer reason: Immunosuppressive therapy after a renal transplant greatly increases the risk of infection, and early recognition is critical to prevent rapid deterioration and potential graft loss. Fever, flushing, and lethargy are common systemic warning signs of infection that require prompt evaluation and treatment. Cyclosporine can mask typical inflammatory responses, so even subtle systemic symptoms should be reported immediately. Gastrointestinal discomfort and mood/appetite changes are generally less urgent and less specific for life-threatening complications in this context.

Question 4

The nurse is completing a home visit with the client who has an arterial ulcer secondary to PAD. Which statement by the client warrants immediate inter-vention by the nurse?

Accepted Answer

Answer reason:  Clients with PAD have impaired perfusion and often reduced protective sensation, so prolonged heat and moisture exposure increases burn and maceration risk and can quickly worsen skin breakdown. Soaking also softens tissue and can promote fissures and infection, which may progress rapidly in an ischemic foot with poor healing capacity. In contrast, protecting an ulcer with sterile gauze and offloading pressure from heels are appropriate measures to reduce further injury. Moisturizing is generally helpful for preventing cracks as long as lotion is not applied between toes and the skin is monitored closely.

Question 5

The nurse is assessing the client who underwent repair of an aortic aneurysm with graft placement 30 minutes ago. The nurse is unable to palpate the posterior tibial pulse of one leg that was palpable 15 minutes earlier. What should be the nurse’s priority?

Accepted Answer

Answer reason: A newly absent distal pulse shortly after aortic aneurysm graft repair indicates acute limb ischemia from impaired arterial perfusion (e.g., graft occlusion/embolization/thrombosis) and is a time-critical complication. Rapid escalation is required to restore blood flow and prevent irreversible tissue injury, neurologic deficit, or limb loss. Waiting to “recheck” or simply repositioning delays definitive evaluation and treatment when a previously present pulse has disappeared. Documentation is important, but it is not the priority over immediate provider notification and urgent intervention.

Question 6

The client residing in a long-term care facility has type 2 DM and is sick with the stomach flu. The client's blood glucose is 245 mg/dL. Which action should the nurse take next?

Accepted Answer

Answer reason: Acute illness raises counterregulatory hormones, increasing hyperglycemia and the risk of ketosis, even in clients with type 2 diabetes. With a blood glucose of 245 mg/dL during a GI illness, the priority next nursing action is to assess for ketones to screen for evolving diabetic ketoacidosis or significant ketosis requiring escalation of care. Holding all intake (NPO) can worsen dehydration and does not address the immediate need to evaluate for metabolic decompensation. Simply rechecking every 6 hours risks delaying recognition of a potentially urgent complication.

Question 7

The nurse is preparing to discharge the client following a unilateral adrenalectomy to treat hyperaldosteronism caused by an adenoma. Which instruction should be included in this client’s discharge teaching?

Accepted Answer

Answer reason: Ongoing home monitoring helps detect hypotension from reduced mineralocorticoid effect or persistent/recurrent hypertension that may require medication titration and provider follow-up. Potassium usually rises toward normal after removal of an aldosterone-secreting adenoma, so avoiding potassium is not a routine instruction unless hyperkalemia develops. Routine emergency epinephrine carriage is unrelated, and medication changes should be directed by the prescriber rather than an automatic stop of all pre-op drugs.

Question 8

The RN is caring for the client following a liver biopsy with the assistance of the student nurse. The RN evaluates that the student understands the postprocedure care when making which observation of the student nurse?

Accepted Answer

Answer reason: Right-side positioning places pressure on the biopsy site and helps tamponade bleeding while limiting bile leakage risk. Early ambulation can increase bleeding risk and is not a first-hour priority. Vital signs are monitored more frequently initially (often q15 minutes then spaced out), and routine coughing/deep breathing is not the key targeted intervention immediately after this procedure compared with bleeding prevention.

Question 9

The nurse is caring for the client who is 6 hours post—open cholecystectomy. The client's T—tube drainage bag is empty, and the nurse notes slight jaundice of the sclera. Which action by the nurse is most important?

Accepted Answer

Answer reason: g., kinked/occluded tube) or impaired bile flow, which can rapidly progress to biliary stasis, leak, or cholangitis. This represents a potential postoperative complication requiring prompt provider evaluation and potential intervention rather than routine monitoring. Nursing measures like repositioning can be attempted, but an empty collection system combined with jaundice is an abnormal finding that warrants escalation. Delegating a blood pressure does not address the priority problem, and simply documenting/monitoring delays treatment of a potentially serious complication.

Question 10

The nurse is caring for the client who has a temporary colostomy following surgery for colon cancer. The nurse assesses that the client’s colostomy bag is empty and that there has been no stool since surgery 24 hours ago. What should the nurse do?

Accepted Answer

Answer reason: In the first 24–48 hours after bowel surgery, it is common for peristalsis to be decreased (postoperative ileus), so lack of stool output from a new colostomy at 24 hours can be an expected finding if other assessments are stable. The safest nursing action is to continue routine monitoring and accurately record the assessment so trends in stoma output and GI function can be evaluated. Escalation is indicated if there are additional warning signs such as abdominal distension, increasing pain, nausea/vomiting, absent bowel sounds beyond the expected window, or signs of obstruction/ischemia. Administering a laxative without a provider order and without assessing for ileus/obstruction risk is inappropriate and could worsen complications.

Question 11

The client is receiving UV light treatments for psoriasis along with methoxsalen, a photosensitizing agent. What precaution should be followed the first day after treatment?

Accepted Answer

Answer reason: Methoxsalen (psoralen) used with UV light (PUVA) markedly increases photosensitivity, including vulnerability of the eyes to UV exposure for hours after treatment. The key first-day safety precaution is protecting the eyes to prevent photokeratitis and long-term lens damage such as cataract formation. Avoiding ointments/lotions is not the primary immediate risk after PUVA and may be appropriate only if they alter UV penetration, but it does not address the highest-stakes complication. Monitoring temperature and stopping for erythema are not the essential first-day post-treatment precaution; erythema is monitored as a treatment response/overexposure sign rather than a universal immediate aftercare step.

Question 12

Three days ago the client received circumferential, partial, and full—thickness burns to 30% total body surface area of the chest and abdomen. The nurse monitors the client for restricted breathing due to Which physiological response?

Accepted Answer

Answer reason: This stiff encasement limits normal chest wall expansion, reducing tidal volume and making ventilation progressively more difficult. The risk is greatest after the first 24–48 hours as the burn wound evolves and the constricting effect becomes more pronounced, so monitoring for increasing work of breathing is essential. Other choices describe parenchymal lung problems (e.g., edema) rather than the classic mechanical restriction created by a circumferential burn to the thorax/abdomen.

Question 13

The client just underwent a left THR. After a family member assists the client with repositioning in bed, the client states hearing a “pop” and has increased pain at the surgical site. Which is the most appropriate initial action by the nurse?

Accepted Answer

Answer reason: A sudden “pop” with acute pain after total hip replacement suggests possible hip dislocation, which requires immediate assessment for classic limb malposition (shortening, internal rotation, adduction) and neurovascular compromise. The nurse’s first priority is to assess the extremity’s position and alignment to identify this complication quickly and prevent further injury. Interventions like adjusting the abduction pillow or elevating the bed may be appropriate after assessment, but they do not confirm the suspected complication. Giving analgesia first risks masking worsening findings and delays urgent evaluation and provider notification if dislocation is present.

Question 14

An hour ago the HCP split the client’s forearm cast due to severe arm pain, throbbing, and tingling. Which most important action should be taken by the nurse when the client’s symptoms return?

Accepted Answer

Answer reason: The nurse’s priority is to further decompress by releasing constrictive padding and widening the bivalved cast to restore perfusion and reduce pressure. Giving IV analgesia can mask escalating ischemic pain and delays the time-sensitive intervention needed to prevent permanent nerve/muscle injury. Elevation above heart level can reduce arterial inflow in suspected compartment syndrome, and while the provider should be notified, immediate cast decompression is the most urgent nursing action when symptoms recur.

Question 15

One month after discharge, the client who had a left THR calls a clinic reporting acute, constant pain in the left groin and hip area and feeling like the left leg is shorter than the right. The nurse advises the client to come to the clinic immediately, suspecting which problem?

Accepted Answer

Answer reason: Dislocation can cause sudden severe pain, functional impairment, and visible or perceived shortening due to malalignment of the femoral component. DVT more typically presents with calf swelling, warmth, and tenderness rather than hip joint pain and limb-length change. Aseptic loosening is generally a chronic, progressive problem occurring months to years later, not abrupt one-month post-discharge symptoms.

Question 16

The client, diagnosed with an ischemic stroke, is being evaluated for thrombolytic therapy. Which assessment finding should prompt the nurse to withhold thrombolytic therapy?

Accepted Answer

Answer reason: Thrombolytic therapy carries a major risk of life-threatening intracranial hemorrhage, so any recent significant head trauma is a key contraindication due to potential occult bleeding or vulnerable intracranial vessels. A serious head injury within the past few months substantially increases bleeding risk and should lead to withholding and further provider evaluation. In contrast, a CT showing no bleeding is a required safety criterion to proceed, not a reason to stop. Symptom onset 2 hours ago is within the treatment window for IV thrombolysis, and diabetes history alone is not an absolute contraindication.

Question 17

The nurse is assessing the client’s right groin puncture site after a renal angiogram finds a saturated, bloody dressing and blood pooling on the sheets. What should be the nurse’s priority?

Accepted Answer

Answer reason: Active bleeding at a femoral access site is an immediate, potentially life-threatening complication due to risk of rapid hemorrhage and hypovolemic shock. The priority is to stop the bleeding by applying firm manual pressure over the site (through the dressing) while maintaining sterile precautions as able and calling for assistance. Removing the dressing delays hemostasis and can worsen bleeding, and simply reinforcing the dressing may conceal ongoing hemorrhage without controlling it. Flexing the leg is contraindicated because it can disrupt the puncture site; the client should remain supine with the affected extremity kept straight.

Question 18

The client with CF is visiting with the nurse in preparation for leaving home for college. Which client statement should the nurse clarify?

Accepted Answer

Answer reason:  Cystic fibrosis care prioritizes airway clearance; suppressing cough can worsen mucus retention and increase risk of atelectasis and infection. Using an antitussive at night for convenience may reduce effective expectoration and should be discussed to ensure it is appropriate and not interfering with pulmonary hygiene routines. In contrast, coordinating care with the campus health center, maintaining infection prevention behaviors, and supporting exercise are generally beneficial CF self-management strategies. The nurse should clarify the type of “cough medicine,” the symptom being treated, and reinforce that airway clearance should not be compromised.

Question 19

The client is one day post—surgical repair of a retinal detachment. Which assessment finding is most important for the nurse to report immediately to the HCP because it indicates a significant complication?

Accepted Answer

Answer reason: Floaters and blurred vision are classic warning symptoms of retinal pathology and are not expected to newly worsen in an uncomplicated immediate postoperative course. Mild pain, tearing, and scleral injection/dryness are common postoperative findings related to irritation and surface inflammation and are typically managed with routine care. Prompt reporting is critical because delayed treatment can lead to permanent vision loss.

Question 20

The nurse just administered butorphanol tartrate as prescribed to the client in active labor. Following administration of butorphanol tartrate, what is the nurse's most important action to help prevent side effects?

Accepted Answer

Answer reason: Monitoring respirations, oxygen saturation, level of consciousness, and overall vital-sign trends allows early detection of hypoventilation and hypoxemia so rapid interventions (stimulation, positioning, supplemental oxygen, provider notification, naloxone if ordered) can be initiated. Seizures are not an expected adverse effect of this medication, and pruritus/rash would indicate allergy but is typically less time-critical than respiratory compromise. Bladder distention can occur in labor but is not a primary medication-related prevention priority compared with airway/breathing surveillance after opioid dosing.

Question 21

The nurse is admitting a neonate after delivery who is diagnosed with a myelomeningocele. Which intervention should the nurse implement immediately?

Accepted Answer

Answer reason: The immediate nursing priority with myelomeningocele is to protect the exposed neural tissue by preventing rupture, trauma, and infection while maintaining moisture. Prone positioning reduces pressure on the sac, and covering it with a sterile dressing provides a barrier to contamination and decreases fluid/heat loss from the exposed area. A pressure dressing is contraindicated because it can compress fragile neural tissue and increase injury. Notifying the surgeon may be necessary, but it does not address the urgent bedside need to protect the lesion right now.

Question 22

The postpartum client, who had a forceps-assisted vaginal birth 4 hours ago, tells the nurse that she is having continuing perineal pain rated at 7 out of 10 and rectal pressure. An oral analgesic was given and ice applied to the perineum earlier. What should the nurse do now?

Accepted Answer

Answer reason: This requires immediate focused assessment of the perineum (and surrounding tissues) to identify swelling, firmness, discoloration, increasing tenderness, and to trend vital signs for occult blood loss. Reporting to the provider is appropriate after rapid reassessment, but the nurse must first evaluate for a time-sensitive complication that can progress quickly. Ambulation and stool softeners do not address the potential hemorrhagic source and could worsen discomfort or delay needed intervention.

Question 23

The nurse is completing discharge teaching for the parents of a child who has hemophilia A. Which is the most important intervention for the nurse to teach the parents in the event that an injury occurs?

Accepted Answer

Answer reason: Immediate hemorrhage control after minor trauma in hemophilia prioritizes local measures that reduce bleeding at the site. Direct, firm pressure is the fastest and most reliable first action caregivers can perform at home to promote hemostasis while arranging further care if needed. Elevation can be a helpful adjunct but is less effective than sustained compression for active oozing/bleeding. Factor IX is incorrect for hemophilia A (factor VIII deficiency) and is not the first home action for every injury.

Question 24

The nurse suspects that the adolescent with NHL has superior vena cava syndrome and notifies the HCP. Which findings support this?

Accepted Answer

Answer reason: This leads to venous congestion and increased venous pressure above the obstruction, producing facial/neck plethora or cyanosis, distended neck veins, and upper-extremity edema. These findings indicate a time-sensitive complication because worsening obstruction can compromise airway and cerebral perfusion. By contrast, the electrolyte pattern in tumor lysis syndrome is metabolic and does not explain prominent upper-body venous congestion.

Question 25

The nurse is caring for the child going home with an indwelling urinary catheter. Which important component should the nurse include in the discharge instructions?

Accepted Answer

Answer reason: A core catheter-care principle is maintaining unobstructed urine flow and preventing retrograde reflux, which reduces the risk of catheter-associated urinary tract infection. Positioning the drainage bag below bladder level uses gravity to promote continuous drainage and prevents backflow of contaminated urine into the bladder. Taping should secure the catheter without traction; “pull and tape” implies tension that can cause urethral trauma and accidental dislodgement. Fluids should generally be encouraged (unless restricted) to help flush the urinary tract and maintain urine output, so reducing intake is unsafe advice.

Question 26

Oxygen via simple facemask is prescribed for the hospitalized child diagnosed with mild intermittent asthma. Which items, brought by the parents from home, should the nurse remove from the room?

Accepted Answer

Answer reason: Many synthetic fabrics and stuffed items can generate static electricity and can also melt/burn rapidly if exposed to an ignition source, increasing fire risk in an oxygen-enriched environment. Removing these items reduces the chance of static discharge and decreases the amount of highly flammable material near the child. By contrast, non-electrical plastic toys and washable cotton items are generally lower risk and easier to keep clean, making them more appropriate when oxygen is in use.

Question 27

A client had coronary artery bypass graft (CABG) surgery 3 days ago. The nurse notes a decrease in the client’s platelet count from 230,000/μl to 5,000/μl. The nurse determines the client may be developing?

Accepted Answer

Answer reason: A sharp postoperative platelet fall occurring a few days after cardiac surgery strongly suggests a heparin-related immune complication from intraoperative and postoperative heparin exposure. This condition is dangerous because it is prothrombotic despite thrombocytopenia, so the key nursing concern is recognizing it early to prevent new thrombosis and embolic events. Other causes like ITP are not typically triggered by recent heparin exposure and are less characteristic of the immediate post-CABG context. DIC can occur with severe systemic illness, but the timing tied to heparin exposure after CABG makes this complication the most likely.

Question 28

A client has experienced an exacerbation of systemic lupus erythematosus (SLE). The nurse determines further teaching is necessary when the client makes which statement?

Accepted Answer

Answer reason:  In SLE, immune dysfunction and common use of immunosuppressants increase infection risk and can precipitate flares, so infections require prompt evaluation and treatment. Minimizing UV exposure is appropriate because photosensitivity can trigger cutaneous and systemic exacerbations. Stress management is also appropriate because physiologic stress can worsen autoimmune activity. Dismissing a potential bacterial infection is unsafe and reflects a knowledge gap about complications and when to seek care.

Question 29

A 25-year-old male client has just had a plaster cast applied to the right forearm following the reduction of a closed radius fracture due to an in-line skating accident. What is the priority assessment for the nurse to perform?

Accepted Answer

Answer reason: Checking distal sensation and active movement evaluates peripheral nerve function and distal perfusion status in the extremity beyond the cast. Pain assessment is important, but pain alone is less specific and must be interpreted in the context of neurovascular findings; the priority is to assess circulation and nerve function first. Cast dryness and petaling affect comfort/skin integrity but are not as immediately limb-threatening as impaired distal neurovascular status.

Question 30

Which nursing diagnosis is appropriate for a client with diabetes who is placed in skeletal traction after a motor vehicle collision?

Accepted Answer

Answer reason: Skeletal traction uses transcutaneous pins that create a direct portal for pathogens, making pin-site infection a key anticipated complication requiring focused nursing surveillance and interventions. Autonomic dysreflexia is primarily associated with spinal cord injury at or above T6 rather than routine bed rest. The other options are either not specific to traction/diabetes risk (malabsorption) or less central than the high-probability, high-impact pin-site infection risk.

Question 31

A client is admitted to the hospital with a subarachnoid hemorrhage and is now experiencing severe headache, nuchal rigidity, and projectile vomiting. The nurse is aware that a lumbar puncture (LP) would be contraindicated if?

Accepted Answer

Answer reason: LP can rapidly lower pressure in the spinal CSF space, and when intracranial pressure is elevated this pressure gradient can precipitate brain herniation. The client’s projectile vomiting and severe headache are classic warning signs consistent with increased ICP, making LP a high-risk procedure until elevated pressure is excluded/managed (often via neuroimaging first). Ongoing vomiting alone is not a strict contraindication, though it may affect positioning/aspiration risk. Anticipating blood in CSF is expected with subarachnoid hemorrhage and is not itself a reason to avoid the procedure.

Question 32

While assessing a 77-year-old client who had a thromboembolic right stroke, the nurse notes the left arm is swollen. The nurse suspects this finding may indicate?

Accepted Answer

Answer reason: Dependent edema can occur when paralysis or decreased spontaneous movement eliminates the skeletal-muscle pump that normally promotes venous and lymphatic return from an extremity. After a right-sided stroke, the left arm is often weak and relatively immobile, predisposing it to venous pooling and swelling. This explanation fits a localized, dependent swelling in the affected limb without requiring evidence of thrombosis. DVT is a key concern but is more typical in the lower extremities and would usually prompt assessment for unilateral pain, warmth, erythema, and risk factors rather than being the most direct physiologic explanation for arm swelling noted on routine assessment.

Question 33

A client is scheduled to undergo a pneumonectomy. The nurse determines that the client understands the rationale for cutting the phrenic nerve and hemidiaphragm paralysis when the client states the procedure will?

Accepted Answer

Answer reason: After pneumonectomy, a large residual hemithorax space can predispose the client to mediastinal shift and impaired cardiopulmonary mechanics if not managed. Phrenic nerve interruption causes ipsilateral hemidiaphragm paralysis and elevation, which decreases the empty thoracic cavity volume. This helps stabilize intrathoracic pressures and supports postoperative respiratory/circulatory function. Increasing the capacity of the remaining lung is not achieved by diaphragmatic paralysis; the remaining lung expands primarily through compensatory hyperinflation, not surgical reduction of thoracic space.

Question 34

A nurse is teaching wound care to parents after cardiac surgery. Which statement made by the nurse is most appropriate?

Accepted Answer

Answer reason: Normal incision healing can include mild itching, tingling, or altered sensation from tissue repair and superficial nerve irritation, and preparing parents for this reduces unnecessary alarm. Teaching should emphasize expected findings versus signs of infection or dehiscence, and this statement appropriately sets expectations without promoting unsafe care. Lotions/powders are typically avoided on fresh incisions because they can irritate the wound and increase infection risk. Tub bathing is usually delayed until the incision is well healed/cleared by the surgeon, and Steri-Strips commonly loosen and fall off on their own without needing a call unless the wound opens or shows infection.

Question 35

A nurse is caring for a 3-year old child who is one day postoperative after having undergone a ventricular septal defect repair. The child weighs 15 kg. The most appropriate outcome for this child is?

Accepted Answer

Answer reason: Adequate renal perfusion is a key postoperative indicator of sufficient circulating volume and cardiac output. Expected pediatric urine output is at least 1 mL/kg/hr; for a 15-kg child, that is about 15 mL/hr, so 25 mL/hr reflects acceptable perfusion after cardiac surgery. Capillary refill greater than 3 seconds suggests poor peripheral perfusion and would be concerning rather than desired. A pain score greater than 5 indicates inadequate analgesia, and a heart rate less than 70 bpm is abnormally low for a 3-year-old and could signal hemodynamic compromise or medication effect.

Question 36

The nurse is assessing an infant who has just returned to the pediatric unit after undergoing a cleft lip repair. The nurse is aware of the potential for trauma to the suture line and determines that which of the following is the best intervention?

Accepted Answer

Answer reason: Arm restraints (often elbow restraints) are the standard intervention after cleft lip repair because they reliably prevent the hands from reaching the mouth while still allowing circulation and movement at the shoulders. Mittens are less effective because infants can still bring their hands to the suture line and apply pressure or friction. Restricting parental touch is unnecessary and harmful to bonding, and removing protective devices would increase the risk of trauma to the incision.

Question 37

Which instruction should be included in a nurse’s discharge teaching for the parents of a newborn diagnosed with sickle cell anemia?

Accepted Answer

Answer reason: Teaching parents to accurately check temperature supports early detection of fever, which requires urgent medical evaluation in this population. Teaching warning signs such as abdominal pain supports early recognition of splenic enlargement/sequestration and vaso-occlusive complications that can rapidly progress to shock. Iron or B12 supplementation is not routine treatment for this hemoglobinopathy, and routine immunizations are recommended rather than contraindicated (often with additional vaccines/prophylaxis).

Question 38

Which statement by the nurse most accurately explains the need for a child with pauciarticular juvenile rheumatoid arthritis (JRA) to have an annual eye exam?

Accepted Answer

Answer reason:  Pauciarticular JRA is associated with chronic anterior uveitis/iritis that can be asymptomatic early, so the child may not report pain, redness, or visual changes despite active inflammation. Routine eye screening is therefore needed to detect inflammation before it causes permanent complications such as cataracts, synechiae, glaucoma, or vision loss. The key teaching point is that absence of symptoms does not rule out significant eye involvement in this subtype of JRA. Retinal detachment and strabismus are not characteristic complications that drive routine annual ophthalmologic surveillance in JRA.

Question 39

A 9-year-old child is brought to the emergency department with extensive burns received in a restaurant fire. What is the most important intervention by the nurse?

Accepted Answer

Answer reason: Early wound management reduces contamination, helps control fluid and heat loss from damaged skin, and supports subsequent assessment and treatment. Routine prophylactic systemic antibiotics are not the immediate priority and are generally avoided unless infection is present due to resistance risk. Oral fluids are insufficient in extensive burns where rapid intravascular volume loss requires controlled resuscitation, and nutritional support becomes important after stabilization rather than as the first priority.

Question 40

The parents of a 10-year-old child recently diagnosed with asthma ask if the child can continue to play sports. What is the best response by the nurse?

Accepted Answer

Answer reason: Well-controlled asthma should allow children to participate in normal activities, and exercise is encouraged to support overall cardiopulmonary fitness and quality of life. The key nursing teaching is prevention of exercise-induced bronchospasm through good baseline control, trigger management, and following the child’s asthma action plan (often including pre-exercise bronchodilator use if prescribed). Advising restriction to quiet play promotes unnecessary limitation and can worsen conditioning and self-esteem. Stating sports don’t cause attacks is misleading because exercise can be a trigger in some children even though it can be managed safely.

Question 41

The nurse evaluates that the cheat has achieved an expected outcome for the second postoperative day following abdominal surgery under general anesthesia. Which finding supports the nurse’s conclusion?

Accepted Answer

Answer reason: By postoperative day 2, passing gas indicates resolving postoperative ileus and improving gastrointestinal function. The urine output listed is low for 24 hours (often expected to be at least about 30 mL/hr), suggesting possible hypovolemia or renal hypoperfusion rather than an expected outcome. Crackles at the lung bases can indicate atelectasis or fluid overload and are not an expected recovery finding. A pain score of 4/10 after analgesia can be acceptable, but it does not specifically demonstrate recovery of a key postoperative physiologic function as clearly as return of bowel activity.

Question 42

A client at term arrives in the labor unit experiencing contractions every 4 minutes. After a brief assessment, she’s admitted, and an electronic fetal monitor is applied. Which observation should the nurse be most concerned about?

Accepted Answer

Answer reason: This finding requires prompt follow-up assessment (repeat BP, symptoms such as headache/visual changes/RUQ pain, urine protein) and close fetal monitoring due to risk of fetal compromise. The other findings are not immediately alarming in labor: 30 lb weight gain is generally within expected range, age 32 is not a high-risk extreme, and treated syphilis earlier in pregnancy is less urgent than current severe-risk physiology if appropriately managed. Intrapartum care prioritizes identifying conditions that can deteriorate quickly and threaten maternal-fetal safety.

Question 43

The client diagnosed with a brain tumor is prescribed intravenous dexamethasone (Decadron), a steroid. Which intervention should the nurse implement when administering this medication?

Accepted Answer

Answer reason: Systemic corticosteroids can raise blood glucose by increasing gluconeogenesis and causing insulin resistance, creating a predictable complication that requires nursing surveillance. With IV dexamethasone—often given in brain tumor care to reduce cerebral edema—hyperglycemia can occur even in clients without diabetes and may worsen infection risk and healing. Monitoring capillary blood glucose allows timely adjustment of diet, antidiabetic therapy, or steroid dosing per orders. While immunosuppression is also a concern, glucose monitoring is the most direct, high-yield safety intervention tied to this medication’s common adverse effect profile.

Question 44

The client is diagnosed with a pituitary tumor and is scheduled for a transsphenoidal hypophysectomy. Which postoperative instruction is important to discuss with the client?

Accepted Answer

Answer reason: Transsphenoidal pituitary surgery creates a pathway through the nasal/sphenoid region, so actions that increase intranasal pressure can disrupt the surgical site and precipitate bleeding or cerebrospinal fluid leakage. Avoiding nose blowing reduces the risk of dislodging packing, opening the incision, and causing complications such as meningitis from a CSF fistula. A key contrast is that dressing care is not the central, high-risk instruction unique to this approach, whereas pressure-raising maneuvers (nose blowing, sneezing with mouth closed, straws) are. Postop teaching therefore prioritizes preventing pressure-related disruption and monitoring for CSF leak symptoms (e.g., clear drainage, salty taste) as part of complication prevention.

Question 45

The male client is being discharged from the ED after sustaining a minor head injury. Which statement indicates the wife understands the discharge teaching?

Accepted Answer

Answer reason: After a head injury, new or worsening neurologic symptoms can indicate increasing intracranial pressure or intracranial bleeding and require urgent evaluation. Repeated vomiting is a red-flag symptom that may reflect deteriorating neurologic status, so returning to the ED is appropriate teaching. Being “hard to wake” is not expected and is itself concerning rather than reassuring. Using leftover pain medication at home is unsafe because the drug may be inappropriate, expired, or sedating and could mask mental status changes.

Question 46

The client is scheduled for right tympanoplasty. Which statement indicates the client understands the preoperative teaching concerning the surgery?

Accepted Answer

Answer reason:  Tympanoplasty repair is vulnerable to pressure changes transmitted through the Eustachian tube into the middle ear. Keeping the mouth open while sneezing or blowing reduces nasopharyngeal pressure and helps prevent graft displacement, bleeding, and disruption of the surgical repair. Dizziness can occur after ear surgery and is often expected unless severe or persistent, so it is not the best indicator of key protective teaching. Predicting permanent hearing loss is inaccurate because the procedure is intended to improve or preserve hearing, and early hair shampooing risks moisture contamination of the operative ear dressing.

Question 47

The nurse provides education to a client after the client receives an initial external beam radiation treatment for melanoma. The nurse should instruct the client to?

Accepted Answer

Answer reason: External beam radiation can cause progressive skin irritation and breakdown, and many topical products can worsen reactions or interfere with the treatment plan. Using only clinician-approved lotions ensures ingredients and timing are safe (e.g., avoiding irritants and not applying products right before a session). The client is not radioactive after external beam therapy, so isolation from others is unnecessary and reflects guidance for some internal radiation sources. Skin markings are used to align the beam accurately and should be protected rather than scrubbed off.

Question 48

The nurse cares for a client with chronic obstructive pulmonary disease (COPD). The physician orders oxygen via nasal cannula for this client. Which action should the nurse take?

Accepted Answer

Answer reason: In COPD, excessive supplemental oxygen can worsen hypercapnia by reducing hypoxic ventilatory drive and increasing V/Q mismatch, leading to CO2 retention and respiratory acidosis. Using the lowest effective flow via nasal cannula supports oxygenation while limiting risk of suppressing ventilation and causing narcosis. A higher flow such as 6 L/min is more likely to raise PaO2 rapidly and precipitate CO2 retention rather than “as needed” self-titration. Teaching the client to adjust the rate is unsafe because oxygen is a medication requiring prescribed titration based on assessment and ordered targets (e.g., SpO2 goals).

Question 49

The nurse cares for a client receiving bolus tube feedings through a Dobhoff tube. The bolus has just been completed. Which position is best for the client?

Accepted Answer

Answer reason: After a bolus tube feeding, the priority is reducing aspiration risk from refluxed formula by maintaining gastric contents below the esophagus. Elevating the head of bed to at least 30 degrees supports gravity-assisted gastric emptying and decreases regurgitation into the airway. A right-lateral position can further promote gastric drainage toward the pylorus, helping move feeding into the small intestine. Positions with the head of bed flat or negative trendelenburg increase aspiration risk, and a 90-degree upright supine position is unnecessary and may be uncomfortable/unstable compared with the standard 30–45 degrees recommendation.

Question 50

A client is status post-thyroidectomy. The client complains of paresthesia and leg cramps. The nurse reviews the client's lab results and notes hypocalcemia. The nurse realizes the reason for the hypocalcemia is?

Accepted Answer

Answer reason: Paresthesias and muscle cramps after thyroid surgery are classic neuromuscular signs of hypocalcemia from reduced parathyroid hormone (PTH). During thyroidectomy, the parathyroid glands can be inadvertently removed or their blood supply compromised, leading to acute hypoparathyroidism and a rapid drop in serum calcium. This mechanism directly explains the postoperative timing and the client’s symptoms. Reduced dairy intake would not typically cause acute, symptomatic hypocalcemia in the immediate postoperative period. Thyroid gland removal affects thyroid hormone levels, not PTH-mediated calcium regulation.

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