Question 1

A client returns from surgery after having a transurethral prostatic resection (TURP) due to benign prostatic hyperplasia. The client has an indwelling urinary catheter in place. Which type of drainage should the nurse expect to see during the immediate postoperative period?

Accepted Answer

Answer reason: Immediate post-TURP bleeding is expected because prostatic tissue has been resected, leaving a raw surgical bed that commonly oozes. With an indwelling catheter (often with continuous bladder irrigation), urine is typically pink to red initially and should gradually lighten as bleeding decreases. Clear, yellow output would be less typical right away and may suggest the irrigation is overly diluting the effluent or that the question’s expected normal finding is being missed. Scant drainage is concerning for catheter obstruction/clot retention rather than an expected postoperative pattern.

Question 2

Which instruction should be included in the care plan for a client following total hip replacement?

Accepted Answer

Answer reason: Hip flexion beyond 90 degrees increases the risk of posterior dislocation, especially when combined with adduction and internal rotation. Therefore, limiting hip flexion is a key care-plan instruction for positioning, transfers, and sitting. In contrast, keeping the legs adducted and sitting with hips lower than knees both promote risky hip positions, and bending forward to don socks/shoes violates the hip precautions.

Question 3

The nurse is caring for a child with a Harrington instrumentation rod placement. While assessing the child on the second postoperative day, the nurse is most concerned when the data include which finding?

Accepted Answer

Answer reason: Oliguria on postoperative day 2 can indicate hypovolemia, third spacing, or evolving renal impairment, which requires prompt assessment of vital signs, intake/output trends, hydration status, and possible provider notification. The other findings listed are expected or common after major spine surgery: a low-grade temperature can occur from atelectasis or normal inflammatory response, incisional pain is anticipated, and hypoactive bowel sounds are common after anesthesia and opioid use. Because reduced urine output can rapidly signal a potentially serious complication, it is the most concerning finding.

Question 4

The nurse is assessing a child after a cardiac catheterization. Which of the following findings requires an immediate phone call to a physician?

Accepted Answer

Answer reason: A weak, thready pedal pulse distal to the catheterization site suggests compromised circulation and risks acute limb ischemia, which requires urgent provider evaluation and potential intervention. In contrast, a low-grade temperature such as 99°F is not concerning, urine output of 2 mL/kg indicates adequate renal perfusion, and slight sanguineous drainage can be expected with close monitoring unless it becomes brisk bleeding or expanding hematoma. Prompt escalation helps prevent permanent neurovascular damage to the extremity.

Question 5

The client is hospitalized with a large bowel obstruction resulting in massive abdominal distention. Which assessment findings should be most concerning to the nurse?

Accepted Answer

Answer reason: Diminished breath sounds at the bases suggests impaired ventilation and loss of aeration, which can rapidly worsen oxygenation and increase risk for respiratory failure, especially in a hospitalized patient. In contrast, high-pitched “tinkling” sounds and colicky pain are expected findings with bowel obstruction and are less immediately life-threatening than evolving ventilation impairment. A urine specific gravity of 1.020 is within normal range and does not indicate an acute complication compared with potential respiratory compromise.

Question 6

The assessment of a client on the first day after thoracotomy shows a temperature of 100° F (37.8° C); heart rate, 96 beats/minute; blood pressure, 136/86 mm Hg; and shallow respirations at 24 breaths/minute, with rhonchi at the bases. The client complains of incisional pain. Which nursing action is most important?

Accepted Answer

Answer reason: The priority after thoracotomy is preventing and treating early postoperative respiratory complications such as atelectasis and retained secretions, which can quickly impair oxygenation. Shallow tachypnea with rhonchi at the bases indicates poor lung expansion and secretion accumulation, making airway clearance and alveolar recruitment the most urgent need. Directed coughing and deep breathing (often with incentive spirometry and splinting) addresses the immediate physiologic risk and helps reverse atelectasis-related low-grade fever. Pain management and ambulation are important supportive measures, but they are secondary because they primarily facilitate effective ventilation rather than directly resolving the current respiratory compromise. Treating the mild fever alone does not correct the underlying pulmonary problem.

Question 7

A 20-month-old toddler has been treated with permethrin (Nix) for scabies. Because he continues to scratch, his mother wonders whether the drug is working. Which response by a nurse is most appropriate?

Accepted Answer

Answer reason:  Persistent itching after scabies treatment often reflects a hypersensitivity reaction to mite antigens rather than ongoing infestation, so symptoms can linger even when mites are eradicated. This response appropriately reassures the parent and sets an expected course, reducing unnecessary retreatment and overexposure to topical insecticides. Advising daily application is unsafe and inconsistent with standard scabies regimens, which typically require a single application with possible repeat in about a week. Suggesting the medication is unsafe under age 2 is incorrect for permethrin 5%, and attributing pruritus specifically to age or permethrin itself misses the key post-scabetic reaction concept.

Question 8

A full-term neonate was just admitted to the transitional nursery. He has a large meningomyelocele covered by an intact sac. The nurse knows immediately to place this neonate on his stomach with hips slightly elevated. Which statement describes the rationale for this position?

Accepted Answer

Answer reason: Prone positioning with the hips slightly elevated keeps pressure off the lesion and minimizes friction against linens/diapers, reducing risk of tearing the sac. It also promotes drainage away from the defect and helps protect exposed neural tissue until surgical repair. Options about preserving bowel/bladder control or facilitating assessment do not address the immediate life-threatening risk of sac rupture and infection.

Question 9

Which statement by the nurse best explains why it’s important to empty the bowel before treatment with intracavitary radiation for cancer of the cervix?

Accepted Answer

Answer reason:  Intracavitary brachytherapy depends on stable positioning of the applicator so the prescribed dose is delivered accurately to the cervix while minimizing exposure to surrounding organs. Bowel filling and subsequent peristalsis/defecation can change pelvic pressures and anatomy, which may shift the applicator and radiation source. This displacement can reduce treatment effectiveness and increase radiation to adjacent tissues such as the bladder and rectum. The other options focus on discomfort, infection, or ileus, which are not the primary safety rationale for bowel emptying in this procedure.

Question 10

A client had a transurethral prostatectomy for benign prostatic hypertrophy and is currently being treated with a continuous bladder irrigation. He's complaining of an increase in severity of bladder spasms. Which intervention should the nurse do first?

Accepted Answer

Answer reason: Increasing bladder spasms during continuous bladder irrigation most commonly indicate catheter obstruction from clots or poor drainage, causing bladder distention and irritation. The nurse’s first priority is to assess and correct a potentially reversible mechanical problem to prevent urinary retention, bleeding complications, and increased intravesical pressure. Ensuring patency and drainage addresses the underlying cause rather than masking symptoms. Analgesics or antispasmodics may be appropriate after patency is confirmed, while stopping irrigation and calling the provider is not the first step when obstruction can be assessed and corrected immediately.

Question 11

A client had transurethral prostatectomy for benign prostatic hypertrophy. He’s currently being treated with continuous bladder irrigation and is complaining of an increase in severity of bladder spasms. What should the nurse do first for this client?

Accepted Answer

Answer reason: The nurse’s first action is to verify patency and dependent drainage because relieving obstruction addresses the underlying cause and prevents further bleeding, pain, and retention. Treating pain or giving antispasmodics without first ensuring drainage can mask symptoms while the bladder continues to distend. Stopping irrigation and calling the provider is not the first step when a correctable mechanical cause can be assessed and managed promptly at the bedside.

Question 12

The nurse is caring for the client immediately following insertion of a permanent pacemaker via the right subclavian vein approach. Which intervention should the nurse include in the client’s plan of care to best prevent pacemaker lead dislodgement?

Accepted Answer

Answer reason: Limiting the ipsilateral arm above shoulder height during the immediate post-op period reduces mechanical pull on the lead and the generator pocket while tissues begin to stabilize. Incision checks address bleeding/infection risk but do not specifically reduce lead movement. A post-procedure chest x-ray is useful to assess lead position and pneumothorax, but it does not prevent dislodgement the way activity restriction does.

Question 13

The nurse completes teaching the client with a newly inserted ICD. Which statement, if made by the client, indicates that further teaching is needed?

Accepted Answer

Answer reason:  An ICD shock can occur when the client is still conscious and has an effective pulse, so CPR is not automatically indicated after a single shock. The appropriate response is to assess the client and call emergency services if the client has symptoms (e.g., chest pain, severe shortness of breath, syncope) or if there are multiple shocks in a short period, which can indicate an unstable rhythm. Initiating CPR when the client is awake with a pulse is inappropriate and could cause harm. The other statements reflect expected ICD function, common patient concerns about shock sensation, and typical driving restriction counseling.

Question 14

The nurse plans teaching for a 20-year-old newly diagnosed with hypertrophic cardiomyopathy. The client is on the college soccer team. Which information should be the nurse's priority when teaching the client?

Accepted Answer

Answer reason: Hypertrophic cardiomyopathy increases the risk of malignant ventricular dysrhythmias and sudden cardiac arrest, especially during exertion in young athletes. Priority teaching focuses on immediate safety planning and preparedness for a life-threatening event at home, so educating household members on CPR directly addresses the highest-consequence complication. Encouraging continued competitive soccer is unsafe because intense exercise can precipitate syncope or arrest in this condition. Genetic counseling and diet education can be appropriate later, but they do not mitigate the immediate risk of sudden death as effectively as CPR readiness.

Question 15

The nurse assesses the client returning from a coronary angiogram in which the femoral artery approach was used. The client’s baseline BP during the procedure was 130/72 mm Hg, and the cardiac rhythm was sinus rhythm. Which finding should alert the nurse to a potential complication?

Accepted Answer

Answer reason: A sudden tachycardia with an irregularly irregular rhythm is concerning for a new atrial dysrhythmia (e.g., atrial fibrillation) that can reduce cardiac output and increase risk of thromboembolism, requiring prompt assessment and intervention. In contrast, a small ecchymotic area with a soft groin is consistent with minor expected local bruising, and +1 pedal pulses can be acceptable if unchanged from baseline and symmetric. A modest BP increase without other symptoms is less specific for an acute post-procedure complication than a new unstable rhythm.

Question 16

The client states to the clinic nurse, “I had pain in the left calf for a few days earlier in the week, but I am pain free now.” The nurse’s assessment findings include: dorsalis pedis pulses palpable, no pain upon dorsiflexion bilaterally, a few visible varicose veins in each leg, and slight swelling in only the left leg. Which is the nurse’s best action?

Accepted Answer

Answer reason: Unilateral leg swelling with a recent history of calf pain raises concern for deep vein thrombosis, which can embolize even if pain has resolved. A negative Homan’s sign (no pain on dorsiflexion) does not reliably rule out DVT, so the nurse must escalate for prompt medical evaluation and diagnostic testing. Palpable pedal pulses suggest arterial perfusion is intact and do not exclude a venous clot. Suggesting aspirin or minimizing findings could delay appropriate workup and increase risk of pulmonary embolism.

Question 17

The nurse explains “watchful waiting” (ongoing visits to a physician for observation of signs and symptoms without treatment) to the client with prostate cancer. Which client is a candidate for “watchful waiting”?

Accepted Answer

Answer reason: A 75-year-old with an estimated 5-year life expectancy and low-grade disease fits the risk–benefit profile where observation is safer and more aligned with goals of care. Metastatic disease and extracapsular extension imply more advanced/aggressive cancer, where close monitoring alone risks progression and symptom burden. An elevated PSA without confirmed low-risk localized cancer is not, by itself, the classic indication for watchful waiting in a client already diagnosed with prostate cancer.

Question 18

The nurse determines that the fluid status of the client with a second-degree bum is inadequate and immediately notifies the HCP. The client is 5 hours postburn and weighs 60 kg. Which findings prompted the nurse’s action?

Accepted Answer

Answer reason: In adults, a key goal is maintaining urine output at least about 0.5 mL/kg/hr; for 60 kg this is ~30 mL/hr, so 25 mL/hr is below target and suggests inadequate renal perfusion/volume. Marked tachycardia further supports compensatory response to intravascular depletion and risk for burn shock. The combination of low urine output with significant tachycardia is more concerning than isolated mildly abnormal vitals and warrants immediate provider notification and likely adjustment of fluids.

Question 19

The nurse assesses the client 6 hours following a lumbar spinal fusion. The client has a throbbing headache, but VS and CMS of the lower extremities are WNL. The lungs have fine basilar crackles. The back dressing has a dime-sized bloody spot surrounded by clear yellow drainage. Which nursing action demonstrates the nurse’s best clinical judgment?

Accepted Answer

Answer reason: The clear fluid suggests abnormal wound drainage rather than expected serosanguinous spotting, making this a priority complication despite stable vital signs and intact distal circulation/motion/sensation. Reinforcing the dressing or treating pain could delay recognition and appropriate management of a potential CSF leak. While pulmonary hygiene is important, the suspected neurologic/surgical complication is the more urgent finding to report and address.

Question 20

The client, who has a deteriorating status after having a stroke, has a rectal temperature of 102.3°F (39.1°C). Which should be the nurse’s rationale for initiating interventions to bring the temperature to a normal level?

Accepted Answer

Answer reason: Elevated temperature also amplifies inflammatory and excitotoxic pathways, contributing to secondary neuronal injury and poorer neurologic outcomes. Therefore, active temperature management is a complication-prevention priority in acute neurologic deterioration. The distractors are incorrect because the key rationale is neuroprotection by limiting infarct expansion, not immune “strengthening,” and lowering temperature to hypothermia is not a routine nursing goal in standard stroke care; GCS would be expected to improve, not decrease, with stabilization.

Question 21

The client tells the nurse that she is considering breast reduction but wants to know if she could breastfeed in the future after this procedure. Which response by the nurse is correct?

Accepted Answer

Answer reason:  Future lactation after reduction mammoplasty depends on preservation of functional glandular tissue, ducts, and nerve supply that support milk production and ejection. When the nipple-areola complex remains connected via a pedicle to underlying breast tissue, ductal pathways and innervation are more likely to remain intact, making breastfeeding possible. Statements claiming no effect or that breastfeeding will be impossible are overly absolute and ignore variation in surgical technique and tissue preservation. Milk production is not universally prevented by nipple changes alone; the key issue is whether the ductal/nerve connections are maintained.

Question 22

The client, with known benign prostatic hyperplasia (BPH), telephones the clinic nurse with concerns of increased urinary frequency and urgency after having a cold that started a few days ago- Which question should the nurse immediately ask the client?

Accepted Answer

Answer reason:  Clients with BPH are at risk for acute urinary retention when exposed to medications that increase bladder outlet resistance or reduce detrusor contractility. Many OTC cold products contain sympathomimetics (e.g., pseudoephedrine/phenylephrine) and/or antihistamines, which can worsen lower urinary tract symptoms and precipitate obstruction. This is a high-yield, time-sensitive safety screen because identifying the trigger allows immediate cessation and prevents progression to retention and complications. The other questions do not directly address a common, reversible medication-related cause of sudden symptom worsening after a recent cold.

Question 23

The nurse is planning care for the client who had a TRAM (transtecus abdominis myocutaneous) flap breast reconstruction. Which actions should the nurse include?

Accepted Answer

Answer reason: Early detection of compromised perfusion is the priority after a flap reconstruction because vascular occlusion can rapidly lead to flap ischemia and necrosis. Frequent neurovascular-type flap checks (color, temperature, and capillary refill) allow the nurse to identify arterial insufficiency (cool, pale, delayed refill) or venous congestion (dusky, swollen) promptly and escalate care. Immediate, routine passive ROM of the affected side can place tension on incisions and jeopardize the reconstruction, so activity is typically restricted initially. Pressure dressings and dependent positioning of the arm are not standard priorities and may impair circulation or increase edema rather than protect flap viability.

Question 24

The client with COPD is in the third postoperative day following right-sided thoracotomy. During the day shift, the client required 10 L of oxygen by mask to keep oxygen saturation levels greater than 88%. Which action should be taken by the evening shift nurse?

Accepted Answer

Answer reason: A sudden need for high-flow oxygen to maintain a COPD-appropriate saturation goal suggests possible postoperative respiratory deterioration and requires prompt assessment and escalation. The nurse should first evaluate ventilation status (including respiratory rate) and then communicate the change to the provider because it may reflect complications such as atelectasis, pneumonia, mucus plugging, or worsening V/Q mismatch after thoracotomy. Attempting to rapidly wean oxygen risks hypoxemia and ignores the underlying cause of increased oxygen requirement. While bronchodilator therapy or analgesia may be helpful, they are not appropriate substitutes for recognizing and reporting a potentially serious change in respiratory status.

Question 25

The nurse is reviewing the new nurse’s discharge instructions for the client following outpatient cataract surgery. Which statement should the experienced nurse remove from the discharge instructions?

Accepted Answer

Answer reason: After cataract surgery, discharge teaching prioritizes preventing increases in intraocular pressure to protect the surgical site. Frequent coughing can raise intraocular pressure and increase risk of complications such as wound disruption or bleeding, so it is not an appropriate routine instruction. Activity limits and positioning guidance are commonly included to avoid strain and pressure on the operative eye. Eye hygiene should be taught using clean materials and gentle technique to reduce irritation and infection risk.

Question 26

The oncoming shift nurse assesses the fundus of the postpartum client 6 hours after a vaginal birth and finds that it is firm. When the nurse then assists the client out of bed for the first time, blood begins to run down the client's leg. Which action by the nurse in response to the client's bleeding is correct?

Accepted Answer

Answer reason: The immediate priority is safety and rapid reassessment, so the nurse should return the client to bed to evaluate amount of bleeding, vital signs, uterine tone/position, and perineum while reducing fall/syncope risk. Explaining it as “normal” delays assessment and could miss a hemorrhage source despite a firm uterus. Provider notification may be needed after assessment, but the first correct nursing action is to get the client safely back to bed for prompt evaluation.

Question 27

The parents and their 9-year-old child with type 1 DM have been given instructions about diabetes. Which statement, if made by the child, best indicates to the nurse that the client understood the teaching?

Accepted Answer

Answer reason:  Persistent hyperglycemia in type 1 diabetes increases risk for ketosis and diabetic ketoacidosis, so screening for ketones when glucose is markedly elevated is a key safety self-management step. A threshold around 240 mg/dL is commonly taught as the point to check urine/blood ketones, especially if the child is ill or has symptoms. Sitting and resting with dizziness during exercise fails to address likely hypoglycemia, which requires rapid-acting carbohydrates and notifying an adult. Giving glucagon is reserved for severe hypoglycemia with inability to safely take oral carbs, and it should be administered by a trained caregiver rather than relying on a child to self-inject as an initial response.

Question 28

The 5-year-old child who has been diagnosed with peritonitis secondary to a ruptured appendix has abdominal pain and nausea, even though an NG tube is in place. When pulling back the covers, the nurse notes that the child's abdomen is distended. Which action should the nurse take first?

Accepted Answer

Answer reason: Abdominal distention, nausea, and pain despite an NG tube suggest the tube may not be decompressing the stomach due to kinking, obstruction, displacement, or loss of suction. The nurse should first assess and troubleshoot equipment that directly affects airway/gastric decompression and risk of worsening vomiting and aspiration. Verifying that drainage is actually moving to the collection container is a rapid, noninvasive action that can immediately identify and correct a reversible cause of the child’s symptoms. Calling the provider or giving an antiemetic delays addressing a potentially malfunctioning device, and finishing a full assessment before checking the tube does not prioritize the most likely, quickly correctable complication.

Question 29

The nurse is caring for the newly admitted 1-year—old hospitalized in sickle cell crisis. This is the parents’ only child. Which intervention is priority?

Accepted Answer

Answer reason: Sickle cell crisis is driven by vaso-occlusion from sickled erythrocytes, and dehydration increases blood viscosity and promotes further sickling, worsening ischemia and pain. A priority nursing intervention is to reduce triggers and prevent progression of complications by ensuring adequate hydration (typically alongside oxygenation and pain control). Platelet transfusion is not a standard treatment for vaso-occlusive crisis and would only be indicated for a specific platelet-related bleeding risk. Hydroxyurea is a long-term disease-modifying therapy and is not an immediate priority for a newly admitted 1-year-old in acute crisis, while genetic testing for parents is non-urgent.

Question 30

The college health nurse is teaching the student athlete diagnosed with infectious mononucleosis. The student asks, “Will I be able to play soccer after I rest up for a few days?” Which is the nurse’s best response?

Accepted Answer

Answer reason: Infectious mononucleosis can cause splenomegaly, which increases the risk of splenic rupture with contact sports or any activity that could traumatize the abdomen. The safest teaching emphasizes restricting abdominal-impact activities until the spleen is no longer enlarged, which commonly requires several weeks and individualized clearance. This directly addresses the key complication risk while allowing gradual return to non-contact activity as symptoms improve and provider guidance is followed. Options suggesting no limits or immediate full activity ignore the potentially life-threatening rupture risk, while a blanket 3-month prohibition is not the best general teaching for all cases.

Question 31

The nurse is discharging the 10-year-old who was hospitalized for RF with signs of CHF. What should be the nurse’s priority with discharge teaching?

Accepted Answer

Answer reason: In rheumatic fever with signs of congestive heart failure, preventing cardiac decompensation and recurrent inflammatory injury is the highest-priority discharge goal. Activity limitation reduces myocardial workload and oxygen demand, while strict adherence to prescribed therapy (including secondary prophylaxis and follow-up) is essential to prevent recurrence and progression to chronic valvular disease. Teaching must be directed to the child as well as the parents because a 10-year-old can participate in self-management and nonadherence is a common cause of worsening symptoms and rehospitalization. Options focused on reassurance or emotional support are important but do not address the most immediate safety risk after discharge.

Question 32

The nurse is developing a plan of care for the child with CF. Which outcomes would be best for the nurse to include?

Accepted Answer

Answer reason: This option directly targets key CF outcomes: reduced pulmonary infection burden, age-appropriate weight status, and intact skin (often challenged by frequent sweating, oxygen devices, and illness). Other choices include outcomes that are not CF-focused (e.g., Helicobacter pylori) or contain unsafe/incorrect targets (urine output 0.1 mL/kg/hr indicates severe oliguria), or emphasize general hygiene/adherence without capturing the primary complication risks that drive CF morbidity.

Question 33

A 69-year-old client is admitted to the medical-surgical unit for osteoarthritis. During the health history, the nurse learns that the client has been on prolonged bed rest. What is the most appropriate nursing intervention for this client?

Accepted Answer

Answer reason: Prolonged bed rest increases the risk of immobility complications such as atelectasis/pneumonia and skin breakdown from pressure. Scheduled turning is a primary prevention strategy for pressure injuries and also promotes ventilation and circulation. Coughing and deep breathing helps expand alveoli, mobilize secretions, and reduce respiratory complications common with inactivity. Limiting fluids is not routinely indicated and can worsen dehydration/constipation, while keeping the client still or restricting to only passive ROM increases complication risk rather than preventing it.

Question 34

A client is receiving discharge teaching on early signs and symptoms of compartment syndrome to report to the health care provider. The nurse recognizes that teaching has been effective when the client makes which statement?

Accepted Answer

Answer reason:  Compartment syndrome causes rising pressure within a closed fascial space that reduces perfusion and compresses nerves. Early neurovascular compromise commonly presents as paresthesia (numbness/tingling), often before overt skin changes occur. Prompt reporting is critical because delayed treatment can lead to ischemia, tissue necrosis, and permanent functional loss. Redness and generalized swelling can occur with many less urgent conditions, and skin color change is typically a later sign compared with early sensory changes.

Question 35

The nurse is caring for a client with a hip-spica cast. The nurse is teaching the client caregivers about the need to avoid gas-forming foods. Which of the following statements indicates that the nurse’s teaching has been effective?

Accepted Answer

Answer reason:  The core principle is preventing complications from restricted abdominal expansion and pressure caused by a hip-spica cast, which can worsen discomfort and impair ventilation and GI function. Gas-forming foods increase intestinal gas, which can lead to abdominal bloating that is particularly problematic when the abdomen is partially encased by the cast. Abdominal distension can also increase pressure on the casted area and contribute to pain and reduced appetite. Flatus is a symptom of gas but the clinically relevant complication the teaching targets is distension and its downstream effects; diarrhea and constipation are not direct results of gas-forming foods.

Question 36

A client tells the nurse that he was recently diagnosed with an allergy to Chinese food after he experienced an asthmatic attack. The nurse determines that teaching is successful when the client makes which statement?

Accepted Answer

Answer reason: " Primary prevention for allergy-induced bronchospasm is strict avoidance of the identified trigger because re-exposure can cause recurrent bronchospasm and potentially progression to anaphylaxis. Avoidance reflects accurate understanding of risk reduction and is the safest long-term strategy. Using inhalers prophylactically does not prevent an allergic cascade and could delay appropriate emergency response if a severe reaction occurs. Minimizing frequency (e.g., monthly) still allows exposure, and dismissing the food as a cause contradicts the diagnosis and undermines safety planning.

Question 37

A nurse is helping parents understand when treatments of growth hormone replacement will end. What is the most important statement for the nurse to include?

Accepted Answer

Answer reason: Growth hormone therapy is continued only while linear growth is still possible, which depends on open epiphyseal (growth) plates. As skeletal maturity approaches, clinicians monitor growth velocity and bone age closely and may adjust dosing to optimize remaining height potential until epiphyseal closure ends the response to therapy. A fixed “1 year then taper” plan is not how treatment duration is determined, because the endpoint is growth plate closure rather than an arbitrary time interval. Unlike chronic corticosteroids, recombinant growth hormone does not require a prolonged taper to avoid adrenal crisis; the key safety/efficacy issue is stopping when epiphyseal closure occurs.

Question 38

An adolescent with type 1 diabetes tells the nurse he will be playing football for his school this year. He asks the nurse what he can do to prevent hypoglycemia. What is the best response by the nurse?

Accepted Answer

Answer reason: Exercise increases glucose utilization by muscles and can precipitate hypoglycemia in type 1 diabetes, especially with prolonged or intense activity like football. Having fast-acting carbohydrates available allows early treatment and prevention when activity increases or symptoms begin. Increasing insulin before exercise would worsen the risk because it further lowers blood glucose. Advising a protein snack specifically when glucose is elevated is mismatched to hypoglycemia prevention, since carbohydrate adjustment and glucose monitoring/threshold-based actions are the key preventive steps.

Question 39

A 14-year-old male client with type 1 diabetes mellitus plans to join the basketball team at his school. The practices are twice a week with games on Saturdays. He calls the nurse at his clinic for advice. The nurse should respond with which statement?

Accepted Answer

Answer reason: Exercise increases glucose utilization and can precipitate hypoglycemia in type 1 diabetes, especially with variable intensity and duration such as practices and games. Frequent glucose checks allow the client to recognize trends and intervene early with carbohydrates or insulin adjustments to prevent acute complications. Advising meals to be delayed increases hypoglycemia risk, and deliberately timing insulin to peak during activity is unsafe for the same reason. A fixed 10% change in calories and insulin is not individualized and may worsen hypoglycemia or hyperglycemia depending on baseline control and activity level.

Question 40

After treating her 16-month-old child with permethrin (Elimite) for scabies, the mother is concerned the cream didn’t work because the child is still scratching. What is the best information for the nurse to give the mother?

Accepted Answer

Answer reason: Persistent itching after appropriate scabies treatment commonly reflects an ongoing hypersensitivity reaction to mite antigens and debris rather than treatment failure. Even when the mites are eradicated, pruritus and inflammatory papules can continue for days to weeks, so reassurance and symptomatic relief are appropriate. Recommending daily reapplication is incorrect because standard permethrin regimens are single application with possible repeat in about 1 week if needed, and excessive use can irritate skin. Permethrin is generally considered safe in young children when used as directed, and ongoing itching is not a typical age-specific adverse effect pattern.

Question 41

The nurse receives new orders for multiple clients. Which order should be the nurse’s priority?

Accepted Answer

Answer reason: Nitroglycerin 0.4 mg sublingually (SL) STAT for the client experiencing chest pain Chest pain suggests possible acute coronary syndrome, where time-sensitive actions are needed to prevent myocardial ischemia/infarction and deterioration. A STAT sublingual nitrate is an immediate intervention that can reduce myocardial oxygen demand and relieve ischemic pain while further evaluation is initiated. Incisional pain and agitation are important but are typically less immediately life-threatening than suspected cardiac ischemia and can be addressed after stabilizing the highest-risk condition. A transfusion for hemoglobin 9.5 is generally not emergent in the absence of active bleeding or severe symptoms, and thus is lower priority.

Question 42

The nurse observes the preoperative client using a volume IS. The nurse evaluates that the client demonstrates proper use when which client action is observed?

Accepted Answer

Answer reason: An end-inspiratory breath hold for several seconds promotes collateral ventilation and improves oxygenation by keeping alveoli open. The incorrect “blows” options reflect exhalation into the device, which does not achieve the goal of lung expansion. Inhaling quickly is also suboptimal because it can create turbulent flow and less effective sustained lung inflation compared with a slow, controlled вдох with a brief hold.

Question 43

The nurse is performing a presurgical admission assessment of the client. Which client statement needs the most immediate follow-up?

Accepted Answer

Answer reason:  Perioperative safety prioritizes identifying actions that create immediate, preventable risk during anesthesia and surgery. Taking warfarin on the day of surgery can significantly increase bleeding risk and may indicate the client was not properly instructed to hold anticoagulants, requiring urgent provider notification and likely delay or modification of the plan of care. While beta-blockers are often continued perioperatively, the presence of an anticoagulant in the same statement is the critical red flag because it directly affects intraoperative hemostasis and postoperative complications. The other statements reflect expected NPO status, appropriate planning for directives, or information that is less immediately dangerous than active anticoagulation at the time of surgery.

Question 44

The nurse is caring for a female client who sustained a closed head injury 8 days ago due to a motor vehicle accident. Which signs/symptoms would alert the nurse to a complication of the head injury?

Accepted Answer

Answer reason: After head injury, damage to the hypothalamus or posterior pituitary can reduce ADH release, leading to diabetes insipidus. This causes large volumes of dilute urine with dehydration symptoms such as intense thirst and can progress to hypernatremia and hypovolemia if untreated. At 8 days post-injury, delayed endocrine complications are plausible and require prompt assessment of urine specific gravity, serum sodium/osmolality, and fluid balance. By contrast, nightmares/insomnia are more consistent with psychological stress, and green nasal drainage suggests infectious rhinitis/sinusitis rather than a classic post–head injury complication.

Question 45

The nurse on the rehabilitation unit is caring for the following clients with SCIs. Which client should the nurse assess first after receiving the change-of-shift report?

Accepted Answer

Answer reason: A warm, erythematous, swollen calf is a classic presentation of deep vein thrombosis, a high-risk complication in spinal cord injury due to immobility and venous stasis. This requires immediate assessment because of the potential for pulmonary embolism, which can rapidly become life-threatening. In contrast, inability to move the lower extremities with a T-4 injury is an expected baseline deficit, and psychosocial concerns about independence are important but not urgent. Headache and nausea can indicate complications (e.g., autonomic dysreflexia when lesions are at/above T6), but with an L-2 injury that diagnosis is less likely, making the suspected DVT the priority.

Question 46

The nurse cares for a client with a hip fracture. The nurse understands that it is important for the client to ambulate frequently because?

Accepted Answer

Answer reason: Immobility after a hip fracture increases pressure over bony prominences, impairing perfusion and raising the risk of pressure injuries. Frequent ambulation promotes regular position changes and improves tissue oxygenation, directly reducing this complication risk. It also supports overall recovery by improving circulation and functional mobility, which are core nursing goals during fracture care. In contrast, claims about ambulation directly stimulating red or white blood cell production are not clinically accurate mechanisms for the benefit being tested here.

Question 47

The HCP writes orders for the newly hospitalized client who has polycystic kidney disease (PKD) and dull flank pain, nocturia, and low urine specific gravity dilute urine. Which admission order should the nurse clarify with the HCP?

Accepted Answer

Answer reason: A sodium limit of 500 mg/day is an extreme restriction that can promote hyponatremia and worsen intravascular depletion, especially in a client already producing dilute urine and experiencing nocturia. Typical renal/cardiovascular sodium limits are higher (often around 2 g/day) and individualized based on blood pressure and volume status. The other orders are broadly consistent with PKD management, including supporting hydration, addressing hypertension with a beta-blocker when indicated, and considering genetic counseling because PKD is often inherited.

Question 48

Which nursing intervention has the highest priority for an infant during the first 24 hours after surgery for cleft lip repair?

Accepted Answer

Answer reason: In the immediate postoperative period after cleft lip repair, the priority is preventing airway obstruction and aspiration while protecting the surgical site. Placing the infant prone after feeds promotes oral/nasal drainage of secretions and milk, reducing pooling that can lead to choking and respiratory compromise. This intervention directly targets a high-risk, time-sensitive complication in the first 24 hours—airway and breathing threats—making it higher priority than routine incision care. A common pitfall is focusing on comfort or sucking behaviors; however, sucking can stress the repair and airway protection takes precedence over nonessential soothing measures early on.

Question 49

While the nurse performs nasopharyngeal suction, the client's oxygen saturation measures 86%. Which action should the nurse take?

Accepted Answer

Answer reason: Suctioning can rapidly cause hypoxemia by removing oxygen along with secretions and by triggering vagal responses and bronchospasm. An SpO2 of 86% indicates clinically significant desaturation, so the immediate priority is to stop the stimulus and restore oxygenation. Removing the catheter prevents continued airway irritation/occlusion and allows prompt reoxygenation (and repositioning/ventilation as needed). Waiting with the catheter in place prolongs the hypoxic insult, and continuing suctioning further increases the risk of worsening hypoxemia and dysrhythmias.

Question 50

A client receiving chemotherapy is considered at high risk for developing lysis syndrome. The nurse would anticipate monitoring the client 48 to 72 hours after infusion and assessing which laboratory values?

Accepted Answer

Answer reason: This leads to hyperkalemia, hyperphosphatemia with secondary hypocalcemia, and hyperuricemia, with high risk for acute kidney injury from uric acid and calcium-phosphate precipitation. Therefore the most safety-critical monitoring in the 48–72 hour window is electrolytes plus renal function markers (BUN/creatinine) to detect life-threatening dysrhythmia risk and evolving kidney failure early. The other option sets focus on coagulation, cardiac injury, or liver function and do not target the primary complication pathway of tumor lysis syndrome.

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