Question 1

Which would be the highest priority in regulating the temperature of a neonate?

Accepted Answer

Answer reason: Neonates have a high surface-area-to-mass ratio, thin skin, limited insulation, and immature thermoregulation, so they lose heat rapidly. Preventing heat loss is the safest first-line priority because it addresses the main mechanisms of neonatal hypothermia across the environment and handling. Relying on adding external heat without controlling losses can still allow ongoing cooling and increases risk of overheating or instability. Reducing heat loss also decreases oxygen and glucose consumption that would otherwise rise with cold stress.

Question 2

Which observation by a nurse indicates that an infant in a hip-spica cast is properly positioned?

Accepted Answer

Answer reason: Proper positioning with a hip-spica cast prioritizes airway safety, respiratory expansion, and prevention of aspiration while also reducing pressure-related and neurovascular complications. Elevating the head and trunk modestly supports lung ventilation and helps keep gastric contents from refluxing toward the airway, which is particularly important in infants. A flat position increases aspiration risk and can worsen respiratory effort, while extreme positioning (such as a straight 180-degree alignment) does not provide the head-of-bed elevation typically used to optimize breathing and comfort. Keeping the infant appropriately elevated also aids in cast care by reducing moisture and pressure over dependent areas.

Question 3

A client recovering from a knee replacement has normal saline solution ordered to run at 125 ml/hour I.V. The I.V. bag was hung at 8:00 a.m. It’s now 3:00 p.m., and 300 ml have been infused. A nurse has just come on her shift at 3:00 p.m. Which action is correct?

Accepted Answer

Answer reason: Assess the I.V. site. An unexpected low infused volume compared with the prescribed rate suggests a problem with the infusion system, most commonly catheter occlusion, infiltration, or dislodgement. The immediate safe nursing action is to assess the IV site and equipment (patency, signs of infiltration/phlebitis, kinks/clamps, and pump settings) before making any changes. Increasing the infusion rate without assessment can worsen an infiltration or lead to fluid overload if the line suddenly becomes patent. Discontinuing the IV or substituting oral fluids does not address the likely complication and may delay needed therapy.

Question 4

The 24-year-old female client has had surgery to replace a diseased mitral graft. Which information should the nurse teach the client prior to discharge?

Accepted Answer

Answer reason: Patients with prosthetic/repair mitral valve procedures commonly require long-term anticoagulation, and INR monitoring is essential to keep therapy in the therapeutic range while preventing thromboembolism and bleeding. Routine INR checks allow timely dose adjustments based on diet changes, drug interactions, and individual response. The other options are either nonspecific, not universally required, or describe possible effects without addressing the key high-risk post-discharge complication (clotting/bleeding). This teaching is high priority because inadequate monitoring can lead to valve thrombosis, stroke, or major hemorrhage.

Question 5

The nurse is reviewing discharge instructions for a client who had a dilation and curettage procedure. Which statement should the nurse include in the discharge instructions?

Accepted Answer

Answer reason: After a D&C, the cervix may remain slightly dilated and the uterine lining is healing, which increases risk for bleeding and ascending infection. Limiting strenuous activity reduces the chance of increased uterine bleeding or cramping. Avoiding sexual intercourse for a period supports cervical closure and lowers infection risk. A common misconception is that routine vaginal products are acceptable; however, items placed in the vagina and activities like tub bathing are typically avoided until healing is complete and bleeding has resolved.

Question 6

A 36-year-old client who has never had mumps or a measles, mumps, and rubella (MMR) immunization reports that he was just notified that an 8-yearold child of a family with whom he stayed recently has been diagnosed with mumps. Which treatment should the client receive?

Accepted Answer

Answer reason: Passive immunization can provide immediate, short-term antibodies when the client lacks prior immunity and cannot rely on an active immune response in time. Antibiotics do not treat viral illnesses, and scrotal ice/support are symptomatic measures used only if orchitis develops rather than preventing illness after exposure. Therefore, giving immune globulin best fits the immediate risk-reduction goal following significant exposure in an unimmunized adult.

Question 7

A client with pneumonia is transferred to the intensive care unit for mechanical ventilation. His blood pressure is 70/40 mm Hg, his heart rate is 115 beats/minute, and his respiratory rate is 32 breaths/minute with accessory muscle use. I.V.s are infusing at 150 ml/hour. Urine output is 50 ml for the past 4 hours. This client is most at risk for which of the following?

Accepted Answer

Answer reason: The oliguria (50 mL over 4 hours, ~12.5 mL/hr) despite ongoing IV fluids suggests inadequate effective circulating volume/pressure reaching the kidneys (e.g., shock from severe infection/respiratory failure). Without prompt restoration of perfusion, sustained ischemia can progress to intrinsic tubular injury, but the immediate risk pattern is prerenal. Postrenal causes would require evidence of obstruction (e.g., bladder distention/anuria) and chronic renal failure would not present as an acute perfusion-driven decline.

Question 8

A 75-year-old client is admitted with dehydration. The client’s laboratory results are serum sodium 145 mg/dl, serum potassium 5.0 mEq/L, blood urea nitrogen 29 mg/dl, and serum creatinine 1.3 mg/dl. Based on these results, the nurse determines that the client is at risk for developing which of the following conditions?

Accepted Answer

Answer reason: The elevated BUN with relatively less elevated creatinine is consistent with decreased circulating volume and reduced glomerular filtration, placing the client at risk for worsening renal function. Older adults have less renal reserve and are more vulnerable to hypovolemia-related declines in GFR. While potassium of 5.0 mEq/L is only mildly high and could contribute to dysrhythmia risk if it rises further, the lab pattern most directly signals risk for prerenal acute renal failure.

Question 9

An 80-year-old man is admitted for a cystoscopy with biopsy of the bladder. After obtaining a history, surgery is postponed. Which reason would be the cause to postpone this client’s surgery?

Accepted Answer

Answer reason: An active infection increases the risk of bacteremia/urosepsis when the urinary tract is instrumented and a biopsy is performed. Proceeding can also worsen inflammation and compromise tissue healing, raising postoperative complication risk. Elective invasive urologic procedures are typically delayed until the infection is treated and urine is clear/sterile. By contrast, stopping anticoagulants is often required pre-procedure to reduce bleeding risk and is not, by itself, a reason to postpone when done appropriately.

Question 10

A client with bladder cancer has had his bladder removed and an ileal conduit created for urine diversion. While changing this client’s pouch, the nurse observes that the area around the stoma is red, weeping, and painful. What should the nurse conclude?

Accepted Answer

Answer reason: Peristomal skin that is erythematous, weeping, and painful most commonly indicates chemical dermatitis from urine leakage onto the skin. With an ileal conduit, ongoing exposure to alkaline urine and mucus quickly excoriates tissue if the wafer opening is too large or the seal is poor. A properly fitted faceplate is cut to closely match stoma size/shape to prevent effluent contact and maintain an intact seal. Lubrication is not a standard preventive measure for skin breakdown, and stoma dilation is not a routine requirement for an ileal conduit or a typical cause of peristomal weeping dermatitis.

Question 11

The nurse completes discharge teaching for the client with chronic stage 2 hypertension. Which statement by the client indicates that teaching was effective?

Accepted Answer

Answer reason: Stage 2 hypertension increases risk for acute target-organ damage, and new neurologic/visual symptoms can signal hypertensive emergency or stroke risk requiring urgent evaluation. Promptly reporting sudden vision changes reflects understanding of warning signs and appropriate escalation of care. In contrast, restricting dietary potassium is not a standard hypertension teaching point unless driven by specific medications or renal disease. Advising “rigorous” exercise is unsafe as a starting plan; lifestyle teaching emphasizes gradual, moderate-intensity activity and weight reduction. A BMI of 32 is obese, so aiming to maintain it indicates ineffective teaching about weight management.

Question 12

The client reports pain, tenderness, and redness along the path of an arm vein where potassium chloride (KCL) is infusing IV. Which interventions should the nurse include when responding to this situation?

Accepted Answer

Answer reason: Pain, tenderness, and redness tracking along the vein during an IV infusion indicates chemical phlebitis/irritation, which is a local infusion complication requiring prompt nursing intervention to prevent worsening tissue injury. Potassium chloride is a known vesicant/irritant, so the priority is to stop the infusion and treat the inflamed vein locally with heat to promote vasodilation and comfort. Continuing the infusion (even at a slower rate) risks progression of phlebitis and potential infiltration/extravasation. This presentation does not fit an allergic reaction (which would more typically involve hives, wheeze, or systemic symptoms), so antihistamines and “allergic reaction” documentation are inappropriate.

Question 13

The client recovering from acute pancreatitis who has been NPO asks the nurse, “When can I start eating again?” Which response by the nurse is most accurate?

Accepted Answer

Answer reason:  In acute pancreatitis, oral intake increases pancreatic stimulation and can worsen inflammation, so diet is resumed only after clinical and biochemical improvement. Controlled abdominal pain suggests decreased pancreatic irritation and improved tolerance of feeding. A falling pancreatic enzyme trend (e.g., lipase) supports resolution of the acute process and reduced risk of symptom flare when eating restarts. Return of bowel sounds/flatus reflects GI motility but does not specifically indicate pancreatic inflammation has resolved, making it an unsafe sole criterion.

Question 14

The client is being admitted to a postsurgical unit following anorectal surgery. The nurse reviews the following postoperative orders from the surgeon. Which order should the nurse question?

Accepted Answer

Answer reason: After anorectal surgery, protecting the surgical site and minimizing pain/strain during early bowel movements is a key complication-prevention priority. High-fiber foods increase stool bulk and can stimulate more frequent, larger-volume stools and gas, which may increase discomfort and mechanical stress on a fresh repair; initial recommendations typically focus on soft, easily passed stools with adequate fluids and stool softeners rather than immediate high fiber. Pre-medicating before the first bowel movement and sitz baths after defecation are common comfort and healing-support measures. Positioning with the head of bed slightly elevated is generally acceptable unless specific procedure-related positioning restrictions are ordered.

Question 15

The nurse is assigned to four clients who were diagnosed with gastric ulcers. Which client should be the nurse’s priority when monitoring for GI bleeding?

Accepted Answer

Answer reason: Older adults also have higher baseline risk for complications from peptic ulcer disease and may decompensate more quickly with blood loss. In contrast, H. pylori and alcohol are ulcer risk factors but do not immediately impair hemostasis to the same degree as aspirin. Acetaminophen does not have clinically meaningful antiplatelet effects, so it is less associated with GI bleeding than aspirin/NSAIDs.

Question 16

The nurse is caring for the client who had a left modified radical mastectomy (a total mastectomy with axillary node dissection and removal of the lining over the pectoralis major muscle). Which action by the nurse is appropriate?

Accepted Answer

Answer reason: Avoiding venipuncture, IV therapy, injections, and blood pressure measurements on the operative-side arm reduces trauma and decreases swelling risk. Using the contralateral arm is a standard postoperative precaution to prevent complications and preserve remaining lymphatic function. Elevation and exercises may be part of recovery, but they do not address the key safety priority of preventing iatrogenic lymphatic injury in the affected limb.

Question 17

The nurse is caring for the client with a burn injury. Which findings should prompt the nurse to notify the HCP because the client may be developing sepsis?

Accepted Answer

Answer reason: Temperature 103.2°F (396°C) and heart rate 120 bpm Burn clients are at high risk for sepsis, and early clinical cues include hyperthermia with unexplained tachycardia due to systemic inflammatory response and evolving infection. This combination reflects a concerning hemodynamic stress pattern that warrants immediate provider notification and escalation of sepsis evaluation and treatment. By contrast, a normal WBC can occur early or in immunocompromised states, and pairing it with tachypnea alone is less specific when infection markers are not trending abnormal. The other options point more toward metabolic disturbance or coagulopathy/hypoglycemia rather than the classic early systemic infection picture in burns.

Question 18

The nurse is obtaining a preoperative health history on the client scheduled for revision of facial scars. Which client comment indicates an increased risk for a poor cosmetic outcome?

Accepted Answer

Answer reason:  NSAIDs inhibit platelet aggregation and can increase perioperative bleeding and hematoma formation, which can compromise wound healing and worsen scar appearance. For facial scar revision, even small increases in bleeding or bruising can distort tissue planes and increase inflammation, leading to less favorable cosmetic results. This statement signals a modifiable risk factor that should be addressed preoperatively (typically stopping nonessential NSAIDs per surgeon/anesthesia guidance). Fasting since 10 pm is expected for anesthesia, controlled hypertension is not a primary cosmetic-risk driver when stable, and preoperative anxiety is common but does not directly impair wound cosmesis.

Question 19

The nursing student is caring for the client who had a right TKR 1 day ago. Which action by the student requires the nurse to intervene?

Accepted Answer

Answer reason: An abductor pillow is typically used after total hip arthroplasty to prevent hip dislocation, not as routine care after a knee arthroplasty. Repositioning the operative extremity to place this device can also increase pain and stress the fresh surgical site without clear benefit. By contrast, CPM controls are often patient-operated within ordered limits, early analgesia supports mobility, and properly protected ice reduces swelling and discomfort.

Question 20

The client has been in a body cast for the past 2 days to treat numerous broken vertebrae from a fall. Tire client is reporting dyspnea, vomiting, epigastric pain, and abdominal distention. Which action demonstrates the nurse’s best clinical judgment?

Accepted Answer

Answer reason: These findings after recent body casting are classic for possible cast syndrome (superior mesenteric artery syndrome) or another acute abdominal/respiratory compromise from impaired thoracoabdominal expansion and GI obstruction. Dyspnea with vomiting, epigastric pain, and abdominal distention signals a potentially rapidly worsening complication that requires prompt provider evaluation and likely urgent cast modification (eg, bivalving/windowing) and further assessment. Independent comfort measures or routine antiemetics do not address the underlying mechanical compromise and can delay definitive treatment. Low-flow oxygen may be a temporary supportive measure, but it does not correct the suspected obstructive/compartment effect driving the symptoms and should not replace escalation of care.

Question 21

The nurse is discharging the client after an elective abortion by suction curettage. Which statement should the nurse include in the client’s discharge instructions?

Accepted Answer

Answer reason: Post-procedure teaching after suction curettage prioritizes early recognition of infection and hemorrhage complications. Foul-smelling vaginal discharge suggests endometritis or retained products with bacterial overgrowth and requires prompt evaluation and treatment to prevent sepsis and infertility. In contrast, vaginal douching is contraindicated because it increases the risk of ascending infection, and intercourse should generally be avoided for a period (often about 2 weeks) rather than based solely on discharge stopping. General rest/return-to-work guidance is less critical than identifying and acting on danger signs.

Question 22

During the immediate postoperative period, the nurse obtains two sets of VS that are WNL for the client who had a total laryngectomy and a tracheostomy placement for cancer treatment. Which is the nurse’s priority action at this time?

Accepted Answer

Answer reason: Airway patency is the immediate priority after laryngectomy with a new tracheostomy because mucus plugs and retained secretions can rapidly obstruct the only airway. Assessing stoma secretions helps identify the need for suctioning, humidification, and airway clearance before respiratory compromise occurs, even when early vital signs are normal. Placing the client flat increases aspiration risk and can impair ventilation; postoperative positioning is typically head-of-bed elevation unless contraindicated. While monitoring the surgical dressing for bleeding is important, it is secondary to ensuring a patent airway, and reducing vital-sign frequency is inappropriate in the immediate postoperative period.

Question 23

The nurse is developing a plan of care for the client admitted with a cough, fever, dyspnea, and a diagnosis of pneumonia. Which is the best intervention to include in the client's plan of care to prevent atelectasis?

Accepted Answer

Answer reason: Atelectasis is prevented by promoting lung expansion and reopening collapsed alveoli through sustained maximal inspiration. Incentive spirometry provides repeated deep-breathing maneuvers that increase inspiratory volume, improve alveolar ventilation, and mobilize secretions, making it a primary preventive intervention in clients with pneumonia and dyspnea. Oxygen therapy can improve oxygenation but does not directly recruit alveoli or prevent collapse. Suctioning oral secretions and scheduled coughing can help secretion clearance, but they are less effective than frequent lung expansion exercises for preventing alveolar collapse.

Question 24

The nurse is concerned that the client in a long-term care facility is experiencing retinal detachment. Which intervention should the nurse implement first?

Accepted Answer

Answer reason: Retinal detachment is an ophthalmic emergency in which rapid evaluation and definitive treatment are needed to prevent permanent vision loss. The nursing priority is to promptly escalate care and arrange urgent ophthalmologic management rather than attempting local eye treatments. Measures like shielding or analgesia may be supportive but do not address the time-sensitive complication risk. Irrigation/pressure dressings are for chemical injury or bleeding control and can worsen risk, and patching both eyes/prone positioning is not an appropriate first-line response for suspected detachment.

Question 25

The nurse is educating the parents of the school-aged child newly diagnosed with hyperthyroidism. Until the disease is under control, which instruction should be included in the education provided by the nurse?

Accepted Answer

Answer reason: Uncontrolled hyperthyroidism increases metabolic rate and adrenergic activity, which can cause tachycardia, palpitations, and reduced exercise tolerance; strenuous activity can precipitate dysrhythmias or worsening symptoms. Temporarily limiting vigorous exertion helps reduce cardiovascular stress until thyroid levels are stabilized with therapy. Increasing stimulation would worsen irritability and hyperactivity rather than promote rest. Calorie restriction is inappropriate because these children often need increased calories/protein due to hypermetabolism, and dressing warmly in heat would exacerbate heat intolerance.

Question 26

The nurse is providing teaching to the parents who have a child newly diagnosed with hypoparathyroidism. Which instruction should the nurse include?

Accepted Answer

Answer reason: Hypoparathyroidism causes low parathyroid hormone, leading to hypocalcemia with increased neuromuscular excitability. Early manifestations include perioral tingling, muscle cramps, and spasms/tetany, which parents should be taught to recognize promptly to prevent progression to seizures or laryngospasm. Teaching focused on recognizing these warning signs supports early intervention and reduces complication risk. The distractor about dry, scaly, coarse skin aligns more with hypothyroidism or excessive thyroid hormone suppression rather than hypocalcemia-related complications.

Question 27

The experienced nurse is observing the new nurse caring for the 11-month-old child who is 12 hours postoperative from a cleft palate repair. Which nursing action requires the experienced nurse to intervene?

Accepted Answer

Answer reason: Routine oral suctioning can traumatize the incision line and increase risk for hemorrhage and wound dehiscence; if secretion removal is needed, it should be minimal and typically limited to gentle suctioning of the nasopharynx as prescribed. The other actions are appropriate postoperative care: avoiding hard foods reduces mechanical stress on the repair, elbow restraints may be briefly removed with close supervision to assess skin/IV integrity, and adequate analgesia supports healing and decreases agitation that could lead to the child touching the repair.

Question 28

The HCP has just removed a peanut from the ear of the preschool child. What information is most important for the nurse to include when completing discharge teaching with the parent and child?

Accepted Answer

Answer reason: Parents should know what symptoms warrant prompt follow-up (worsening pain, drainage, fever, hearing change, dizziness) and how to provide ordered care (e.g., prescribed drops, keeping the ear dry if instructed). This directly reduces risk after the immediate intervention, which is the most time-sensitive discharge need. Prevention strategies are important but are secondary to ensuring safe recovery and identifying complications that may already be developing.

Question 29

The nurse is caring for the child who is postoperative tonsillectomy and adenoidectomy (T&A) surgery. The nurse should further explore for signs of hemorrhage when obtaining which assessment finding?

Accepted Answer

Answer reason: Oropharyngeal hemorrhage can trickle down the throat and trigger these repeated behaviors as the child attempts to clear and swallow secretions. This finding warrants prompt assessment of the surgical site and close monitoring for additional bleeding and signs of hypovolemia. In contrast, sore throat and some dried blood at the mouth are commonly expected early postoperative findings and are less specific for active hemorrhage.

Question 30

Which statement by a nurse to the health care aide best explains the need to promptly report changes in respiratory rate for a client diagnosed with heart failure?

Accepted Answer

Answer reason:  In heart failure, worsening left-sided pump function can rapidly increase pulmonary capillary pressure and push fluid into the alveoli, causing acute pulmonary edema. A rising respiratory rate is an early, sensitive sign of increasing work of breathing and impaired gas exchange, so it must be reported immediately for prompt assessment and interventions (e.g., oxygen, diuretics, positioning). This directly ties the aide’s observation to a time-critical, life-threatening complication of heart failure. SARS is an infectious disease unrelated to heart failure, and pneumothorax is not a typical sudden complication of heart failure compared with fluid overload–related pulmonary edema.

Question 31

A recently admitted client is suspected of having peritonitis. He’s requesting a glass of water to drink. Which would be the nurse’s best response to the client?

Accepted Answer

Answer reason:  Suspected peritonitis is an acute abdominal condition where the patient is typically kept NPO to reduce the risk of vomiting and aspiration, limit gastrointestinal stimulation, and prepare for potential urgent diagnostic or surgical intervention. The safest nursing response includes clear patient teaching about why oral intake is restricted and ties it to return of bowel function, which is a key indicator of gastrointestinal readiness. Offering small amounts of water is unsafe because it violates common NPO management for an acute abdomen. Stating only that fluids are IV is incomplete and doesn’t address the safety rationale or the NPO restriction directly.

Question 32

The nurse is reviewing assessment data of clients who may be at risk for developing malignant lymphoma. The nurse determines that the client at highest risk would be?

Accepted Answer

Answer reason: HIV is a strong, well-established risk factor for non-Hodgkin lymphoma and other aggressive lymphomas. In contrast, cigarette smoking is not a primary driver of lymphoma compared with its role in lung and head/neck cancers. Prior mononucleosis (EBV exposure) and a cousin with Hodgkin’s lymphoma may confer some association, but they are generally weaker predictors than significant chronic immunodeficiency.

Question 33

The nurse is caring for a client who is admitted for a herniated nucleus pulposus. The client's pain level is a 10 out of 10. The health care provider ordered a morphine sulfate (Duramorph) patient-controlled analgesic (PCA), which is implemented for the client. What is the priority nursing assessment for this client?

Accepted Answer

Answer reason: The nurse should prioritize assessment of respiratory rate, depth, oxygen saturation, and level of sedation to detect hypoventilation early and intervene promptly (e.g., hold doses, stimulate, apply oxygen, prepare naloxone). Pain relief is important, but airway and breathing take precedence over other system assessments in acute opioid administration. Neurologic and cardiovascular effects can occur, but they are typically secondary to the priority risk of decreased ventilation. GI effects like constipation are expected but are not an immediate priority compared with potential respiratory compromise.

Question 34

A client is diagnosed with fat emboli. Which signs and symptoms would the nurse expect to find during assessment?

Accepted Answer

Answer reason: Sympathetic response to hypoxemia commonly produces tachycardia rather than bradycardia. A petechial rash over the upper chest/neck (and conjunctiva) is a hallmark finding due to occlusion and fragility of dermal capillaries. Options listing bradypnea/bradycardia are inconsistent with the usual acute presentation and would be more concerning for impending respiratory failure or other etiologies rather than typical early fat embolism findings.

Question 35

A client with a cervical spine injury is placed in a Minerva body vest. The client is uncomfortable and would like to try a different device. What is the best response by the nurse?

Accepted Answer

Answer reason: The key principle is preventing secondary spinal cord injury by maximizing cervical immobilization after a cervical spine injury. A Minerva vest provides rigid external stabilization that limits flexion, extension, rotation, and lateral bending more effectively than soft collars, which are inadequate for unstable injuries. Educating the client about the purpose and safety benefit is the most therapeutic and safety-focused response to discomfort-related requests. Options describing only partial benefit are less complete, and suggesting alternative soft collars undermines required immobilization and increases risk.

Question 36

A client with severe eye pain requests a prescription for the topical anesthetic the ophthalmologist instilled. The nurse explains that these drugs should not be used on an ongoing basis for which reason?

Accepted Answer

Answer reason: Topical ophthalmic anesthetics abolish corneal sensation, removing the protective blink reflex and pain warning that normally limits eye rubbing and exposure. With repeated use, patients can unknowingly traumatize the cornea and delay recognition of worsening injury, which increases the risk of corneal abrasion, ulceration, and impaired healing. This is why these agents are reserved for in-office diagnostic/procedural use rather than outpatient pain control. Mydriasis-related blurred vision is more characteristic of anticholinergic/cycloplegic drops, and “dependence/rebound” is not the primary safety concern compared with corneal toxicity and injury.

Question 37

When teaching parents of an infant newly diagnosed with diabetes insipidus, which statement by a parent indicates an understanding of this condition?

Accepted Answer

Answer reason:  Diabetes insipidus causes impaired antidiuretic hormone effect leading to ongoing polyuria and risk for dehydration and electrolyte imbalance, so long-term management is typically required. Recognizing that therapy continues over time reflects understanding that the underlying problem does not usually resolve quickly or “go away” on its own. Parents must continue prescribed hormone replacement (e.g., desmopressin) and monitoring to prevent recurrent complications. Statements minimizing the need for medication or intake monitoring are unsafe because careful fluid balance tracking is central to preventing dehydration in infants.

Question 38

The parents of a child undergoing irradiation are taught about postirradiation somnolence. Which statement, if made by the parents, indicates that the teaching has been effective?

Accepted Answer

Answer reason: Postirradiation somnolence is a delayed, transient CNS effect of cranial radiation, so the key teaching point is expected timing rather than immediate onset. It typically appears several weeks after therapy (commonly around 5–8 weeks), presenting with excessive sleepiness and lethargy that generally resolves. An onset within 1–2 weeks is too early for this syndrome and suggests confusion with acute radiation effects. A 3–6 month timeframe is more consistent with later radiation-related complications rather than the classic somnolence syndrome window.

Question 39

A nurse is caring for a 10-year old in Buck’s traction for a fractured femur following a bicycle accident. The child complains of increasing pain 1 hour after receiving an I.V. opioid analgesic. What is the most appropriate action by the nurse?

Accepted Answer

Answer reason: Increasing pain despite an adequate interval after IV opioid can indicate an evolving complication rather than undertreated pain, particularly in an extremity injury with traction. The priority is to assess for impaired perfusion/nerve compromise (e.g., compartment syndrome or traction-related neurovascular compromise) using pulses, capillary refill, color/temperature, sensation, movement, and pain with passive stretch. Neurovascular compromise is limb-threatening and requires rapid identification and escalation, making assessment the safest immediate nursing action. Checking traction setup is important but does not supersede ruling out acute ischemia/nerve impairment, and giving more opioid could mask worsening findings and delay treatment.

Question 40

The client with a central venous access device suddenly develops dyspnea, chest pain, tachycardia, and hypotension after the nurse attaches new injection caps during a central line dressing change. Which action should be taken by the nurse first?

Accepted Answer

Answer reason: These sudden findings immediately after central line manipulation are most consistent with an air embolism, a life-threatening central venous access complication. The priority is to prevent the air from entering the pulmonary circulation by placing the client in the left lateral Trendelenburg (Durant) position to trap air in the right atrium/ventricle. Oxygen is appropriate but is not the first action when a positioning maneuver can rapidly limit further hemodynamic collapse. Notifying the provider is important after initiating emergency measures, and flushing the line risks worsening the event by pushing air further into the circulation.

Question 41

The nurse is performing presurgical assessment of multiple clients. The nurse determines that which client has the greatest risk for developing an infection postoperatively?

Accepted Answer

Answer reason: In the perioperative period, this immune deficit increases risk even with standard sterile technique and prophylaxis, making it the highest-priority infection-risk finding among the choices. Thrombocytopenia mainly increases bleeding risk rather than infection risk. Diabetes can impair wound healing and raise infection risk, but the immediate, profound infection vulnerability from neutropenia is typically greater than that from newly diagnosed type 1 DM alone.

Question 42

The nurse assesses redness, swelling, and warmth at the client's leg incision 48 hours after femoral popliteal bypass surgery. Which is the nurse's best interpretation of the findings?

Accepted Answer

Answer reason: Redness, warmth, and swelling at a surgical site are classic local inflammatory findings and, in the early postoperative period, warrant concern for developing infection rather than being automatically dismissed as normal healing. At 48 hours, mild incisional discomfort can be expected, but the clustered presence of these signs increases the likelihood of a complication that requires further assessment and monitoring. Suture “rejection” more typically presents with localized irritation or spitting sutures rather than a broader pattern of progressive warmth and swelling. Dehiscence involves separation of wound edges or drainage/evisceration findings, which are not described here.

Question 43

The nurse collects the following information on the postoperative client: serum sodium level of 127 mEq/L; weight gain of 3 lb in 24 hours; crackles in lung bases, BP 154/70 mm Hg, 1+ pitting edema at the ankles. If prescribed, which intervention should the nurse implement?

Accepted Answer

Answer reason: This intervention directly addresses the likely cause of the low sodium (water excess) while supporting gradual correction and reducing risk of respiratory compromise. Hypertonic saline would be reserved for severe/symptomatic hyponatremia and could exacerbate intravascular volume overload if given routinely. A sodium-restricted diet does not correct acute water overload, and an immediate high-dose IV diuretic may be ordered in some cases but is not the best first supportive measure to implement based on the primary finding of dilutional hyponatremia with fluid overload.

Question 44

The new nurse has been oriented to the PACU and is caring for the client who had general anesthesia. The charge nurse determines that the new nurse can correctly position the client in the PACU when making which observation?

Accepted Answer

Answer reason: Lateral (side-lying) positioning promotes drainage of oral secretions or emesis and helps keep the tongue from occluding the airway until the client is more awake. Prone positioning is unsafe and can compromise ventilation and airway access if vomiting occurs. Trendelenburg is not a routine first-line positioning choice for hypotension in the immediate post-op setting and may worsen respiratory mechanics and aspiration risk.

Question 45

The nurse is developing a plan of care for a client diagnosed with septic meningitis. Which client goal would be most appropriate for the client problem of “altered thermoregulation”?

Accepted Answer

Answer reason: Altered thermoregulation in septic meningitis is primarily evidenced by fever due to infection and inflammatory response, so an outcome should directly measure sustained temperature control. A goal of being afebrile over a defined period is specific, measurable, and directly tied to resolving the temperature problem and reducing metabolic demand and neurologic stress. The hypothermia blanket and seizure precautions are interventions/safety considerations rather than the clearest thermoregulation outcome. Normal electrolytes are important monitoring data but do not directly evaluate the core problem of temperature regulation.

Question 46

The nurse cares for a client who has a continuous passive motion (CPM) machine in place after a total knee replacement. The physician writes orders for the degree of flexion and hours per day of CPM use. Which intervention should the nurse perform?

Accepted Answer

Answer reason: CPM therapy after total knee replacement must be delivered exactly as prescribed to prevent complications such as excessive pain, bleeding, or joint/tissue injury from too much flexion. The nurse’s priority intervention is to verify that the device is set to the ordered degree of flexion (and, by implication, the ordered regimen) each day so the therapy being delivered matches the provider’s parameters. Allowing family to change settings or independently increasing flexion exceeds appropriate delegation and risks harm because changes require a provider order. Turning the machine off while eating is not a core safety requirement and does not address the primary risk of incorrect settings.

Question 47

The nurse provides discharge instructions to a client going home with furosemide (Lasix) and potassium (K-Dur). The client asks the nurse why potassium is indicated. Which statement by the nurse is most appropriate?

Accepted Answer

Answer reason: Loop diuretics increase urinary excretion of potassium, creating a common risk for hypokalemia that can lead to weakness and dysrhythmias. The safest discharge teaching explains the direct medication-related reason for the added drug and links it to prevention of a predictable adverse effect. Saying the level is low may be untrue without lab data and does not teach the mechanism. The other statements are either overly vague or incorrect about how furosemide works.

Question 48

A client received a radioisotope bone scan yesterday. The client had no adverse reactions to the radioisotope. This morning, the physician orders another bone scan using a radioisotope because the results from yesterday's scan are inconclusive. The nurse calls the physician to question her order because?

Accepted Answer

Answer reason: Repeated exposure to radiopharmaceuticals increases physiologic burden because the tracer is largely cleared through the kidneys, and additional dosing can increase risk in clients with unrecognized renal impairment or dehydration. A repeat scan the next day should prompt the nurse to question the order and verify renal status, hydration instructions, and whether an alternative timing/approach could reduce risk. Cost is not a clinical safety rationale for challenging an order, and a bone scan is not typically considered an invasive procedure in the same way as surgeries or catheter-based tests. Allergy is possible with any agent, but the client had no prior reaction and the larger immediate safety concern with repeat dosing is potential renal compromise and cumulative exposure.

Question 49

The nurse cares for a client who has a chest tube that is connected to suction. Which interventions should the nurse perform?

Accepted Answer

Answer reason: A chest tube on suction is used to restore/maintain negative intrapleural pressure, so the priority is early detection of impaired ventilation and system malfunction. Respiratory distress monitoring addresses the most immediate complication (recurrent pneumothorax or ineffective lung re-expansion). Checking all connections and the drainage system specifically targets a common preventable cause of failure—air leaks—that can break the seal and stop effective suction. Options that only mention distress omit the critical equipment assessment, and focusing on absent breath sounds is too narrow and may delay recognition of a developing problem.

Question 50

A client returns to the nursing unit after a transurethral prostatic resection. The client has an indwelling urinary catheter with a continuous bladder irrigation system in place. The client complains of bladder spasms. Which priority action should the nurse take?

Accepted Answer

Answer reason: Bladder spasms after TURP with continuous bladder irrigation commonly indicate catheter obstruction from clots or kinking causing bladder distention. The priority is to restore catheter patency to prevent urinary retention, bleeding-related complications, and increased intravesical pressure. Following the order to irrigate/flush addresses the most likely and most immediate reversible cause of the symptom. Simply checking vital signs or calling the provider delays corrective action, and catheter removal is unsafe in the immediate post-TURP period when traction/drainage is needed for hemostasis.

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