Question 1

A 42-year-old client who underwent a right modified mastectomy with insertion of a Hemovac drain will be hospitalized overnight because of minor complications. Which goal statement should the nurse include in the plan of care?

Accepted Answer

Answer reason: A high-quality nursing goal/outcome must be patient-centered, specific, measurable/observable, and time-limited. Demonstrating incision and Hemovac drain care is a directly observable behavior that can be evaluated before discharge, supporting safe self-care and reducing postoperative complication risk (e.g., infection, disrupted drainage). The option using “teach” is a nursing intervention, not a client outcome, and “will know” is difficult to measure reliably. Combining physical care with broad psychosocial coping in a single short-term goal makes the outcome less specific and harder to evaluate.

Question 2

A client is undergoing peritoneal dialysis. The dialysate dwell time is completed, and the clamp is opened to allow the dialysate to drain. The nurse notes that drainage has stopped and that only 500 mL has drained if the amount of dialysate instilled was 1,500 mL. Which intervention should be done first?

Accepted Answer

Answer reason: Poor outflow during peritoneal dialysis is most commonly due to mechanical factors such as catheter tip malposition against the peritoneum/omentum or transient flow blockage that can be relieved with simple, noninvasive measures. Repositioning (turning side-to-side, sitting up, ambulating if allowed) is the safest immediate nursing intervention to re-establish drainage before manipulating the system. If repositioning fails, the next step is to assess for catheter kinking/obstruction in the tubing and ensure clamps are open, because that involves additional handling of the device. Escalating to the provider is appropriate only after nursing troubleshooting measures fail or if there are signs of complications (e.g., severe pain, peritonitis, bleeding).

Question 3

The nurse is discharging a 65-year-old client diagnosed with aortic stenosis who had undergone mechanical valve replacement surgery. Which information should the nurse teach the client?

Accepted Answer

Answer reason: Prosthetic heart valves increase risk for infective endocarditis from transient bacteremia, especially during dental work and other invasive procedures. Prophylactic antibiotics reduce the likelihood of valve infection, which can be life-threatening and lead to valve dysfunction or systemic emboli. This teaching is specific to valve replacement and targets prevention of a major postoperative long-term complication. The other options describe general comfort measures or immunization avoidance, which do not address the key prosthetic-valve–related risk.

Question 4

On the client’s second postoperative day, the nurse assesses that the client has diminished breath sounds in both lung bases, is taking shallow breaths, and achieves only 500 mL on an 18. The client smoked cigarettes for the past 30 years. Which is the nurse’s best interpretation of these findings?

Accepted Answer

Answer reason: Postoperative hypoventilation from pain, shallow breathing, and immobility commonly leads to alveolar collapse, especially at the lung bases. Diminished bibasilar breath sounds plus low incentive spirometry volumes supports reduced lung expansion and developing collapse rather than effective ventilation. Pneumonia is less likely without typical infectious findings (e.g., fever, productive cough, focal crackles) and usually evolves after secretion retention rather than presenting simply as low volumes with shallow breaths on day 2. A primary airway obstruction would more often cause acute respiratory distress with wheeze/stridor or markedly asymmetric airflow rather than isolated bibasilar diminution tied to poor inspiration.

Question 5

A client has just returned from the postanesthesia care unit after undergoing internal fixation of a left femoral neck fracture. The nurse should place the client in which position?

Accepted Answer

Answer reason: After femoral neck fracture fixation, maintaining hip alignment and preventing adduction/rotation reduces the risk of displacement and hip dislocation. Supine positioning with a spacer between the legs keeps the operative extremity in neutral alignment and helps prevent the leg from crossing midline. Side-lying with a bent knee can promote hip flexion, adduction, and internal/external rotation, which increases stress on the repair. Sitting upright to 90 degrees can also increase hip flexion and is generally avoided early unless specifically prescribed and within post-op precautions.

Question 6

The client, admitted to a surgical unit following a TURF, has a CBI running. The nurse assesses the client's urine and finds dark red urine containing several small clots. Which intervention should the nurse implement?

Accepted Answer

Answer reason: After TURP with continuous bladder irrigation, dark red urine with clots suggests increased bleeding and a rising risk of catheter obstruction from clot retention. The safest immediate nursing action is to increase irrigation to maintain catheter patency and help flush clots while closely monitoring output and patient status. Stopping the irrigation can worsen clot formation and precipitate acute urinary retention and bladder distention. Manual irrigation is typically reserved if increasing the CBI does not restore adequate flow or if obstruction is suspected, and deflating the balloon is unsafe because it can disrupt tamponade and increase bleeding.

Question 7

The client underwent a lumbar laminectomy with spinal fusion 12 hours earlier. Which nursing assessment finding indicates that the client has a leakage of CSF?

Accepted Answer

Answer reason: This finding is more specific for a CSF leak than expected postoperative serosanguineous output in a drain. Pain unrelieved by narcotics is nonspecific and can occur from normal postoperative inflammation or inadequate analgesia. A fever spike raises concern for infection but does not directly indicate CSF leakage and is not as immediate or specific a sign as clear drainage at the wound site.

Question 8

A client awaiting surgery is accidentally given a double dose of morning medication, which includes metformin hydrochloride (Glucophage) 1000 mg and aspirin 81 mg. Which step should the nurse take to ensure no ill effects occur as a result of this incident?

Accepted Answer

Answer reason: After an unintended double dose of an antidiabetic agent, the priority is to detect and prevent hypoglycemia, which can rapidly become a perioperative safety threat. Checking blood glucose provides immediate, objective data to guide timely interventions such as administering carbohydrates or adjusting perioperative glucose management. Kussmaul respirations suggest severe metabolic acidosis (e.g., DKA or lactic acidosis) and are not the most sensitive or early indicator to monitor after an extra dose in this context. Hypertension and temperature monitoring do not directly address the most likely acute medication-related complication from this error.

Question 9

The radiology nurse is reviewing a list of home medications of a 53-year-old client who is scheduled for an outpatient I.V. pyelogram (IVP) at 10:00 a.m. The client took the following medications at home with sips of water at 8:00 a.m. Which of the medications would prompt the nurse to contact the physician?

Accepted Answer

Answer reason: Because of this interaction, metformin is typically held around the time of iodinated contrast administration and restarted only after renal function is confirmed to be stable. Taking it shortly before the study raises a preventable complication risk and should be reported so orders can be clarified. In contrast, common home doses of a beta-blocker or a benzodiazepine do not carry the same contrast-related renal/lactic acidosis concern.

Question 10

The male client states to the nurse, “I’ve recovered after having my new artificial heart valve inserted. Now I want to have a vasectomy so I don’t get my wife pregnant.” What is the nurse’s best response?

Accepted Answer

Answer reason:  Clients with prosthetic heart valves are at increased risk for infective endocarditis from transient bacteremia during invasive procedures. The safest nursing response is to direct the client to notify the surgeon so appropriate prophylactic antibiotics can be considered to reduce the risk of valve infection. Advising against the vasectomy is non-therapeutic and does not provide a risk-mitigation plan. Suggesting routine nitroglycerin before intercourse is unrelated to the client’s stated plan and is not an indicated blanket instruction.

Question 11

The nurse is caring for multiple clients. Which client should the nurse identify as having the greatest risk for developing a DVT?

Accepted Answer

Answer reason: DVT risk is driven by Virchow’s triad, especially venous stasis and postoperative hypercoagulability. Major orthopedic surgery (hip arthroplasty) plus immobility produces profound venous stasis, and underlying venous insufficiency further impairs venous return. A markedly elevated platelet count can reflect a hypercoagulable tendency, adding to thrombosis risk. By contrast, a patient receiving therapeutic heparin (prolonged PTT) is being anticoagulated, which lowers the likelihood of forming a new DVT despite past history.

Question 12

The client with type 2 DM is scheduled for cardiac rehabilitation exercises (cardiac rehab). The nurse notes that the client’s blood glucose level is 300 mg/dL and that the urine is positive for ketones. How should the nurse proceed?

Accepted Answer

Answer reason: With marked hyperglycemia and ketonuria, exercise is contraindicated because it can worsen insulin deficiency physiology and raise counterregulatory hormones (catecholamines, glucagon), increasing hepatic glucose output and ketone production. This combination signals risk for evolving ketoacidosis or severe metabolic decompensation, so the priority is to stop the activity and prompt medical evaluation and glucose/ketone management. Sending the patient to exercise (with or without a snack) ignores the safety red flag of ketones at a glucose level around 300 mg/dL. The concern is not exercise-induced hypoglycemia here; it is worsening hyperglycemia/ketosis and dehydration risk.

Question 13

The female client is to be treated with radioactive iodine (RAI) therapy for an enlarged thyroid gland. The client asks if there are any precautions that are needed during RAI therapy. Which is the nurse’s best response?

Accepted Answer

Answer reason:  RAI can expose a developing embryo/fetus to radiation, so pregnancy prevention is a key safety precaution and a standard teaching point for reproductive-age clients receiving this therapy. Advising contraception/abstinence during treatment and for months afterward addresses the primary preventable complication: teratogenic and fetal thyroid injury. The statement that no precautions are needed is unsafe because RAI requires radiation-safety and reproductive precautions. Claims of immediate results and stopping all related meds are inaccurate, and thyroid hormone replacement may be needed if hypothyroidism occurs after ablation.

Question 14

The nurse is caring for the postoperative client who underwent an open Roux-en-Y gastric bypass. The charge nurse should intervene if which observation is made?

Accepted Answer

Answer reason: After Roux-en-Y gastric bypass, protecting the newly created anastomosis and staple lines is a key postoperative safety priority. Routine NG tube irrigation can increase pressure, disrupt suture/staple lines, and raise the risk of bleeding or anastomotic leak, so it should not be performed unless specifically ordered and protocol-driven. The presence of supplies positioned for bedside irrigation suggests an unsafe or non-indicated procedure may be carried out without appropriate authorization. The other observations are typical postoperative measures (small-volume clear liquids progression, timely Foley removal, and use of noninvasive ventilation for sleep-disordered breathing) and are not inherently concerning.

Question 15

The LPN is reporting observations and cares to the RN. Based on the LPN’s report, which client should the RN assess immediately?

Accepted Answer

Answer reason: Severe, persistent pain after a crush injury is a key warning sign for acute compartment syndrome, where rising compartment pressures impair perfusion and can rapidly lead to ischemia and permanent neuromuscular damage. Escalating analgesia and giving a muscle relaxant may mask worsening symptoms and delay definitive evaluation and intervention, so this report requires immediate RN assessment (pain, pallor, paresthesia, paralysis, pulselessness, and tension). In contrast, 100 mL of sanguineous drainage 2 hours after total knee replacement can be expected in a closed drainage/autotransfusion system unless accompanied by hemodynamic instability or rapidly increasing output. Serous pin-site drainage with Doppler-detectable pulses is more consistent with expected findings and routine monitoring rather than an immediately limb-threatening emergency.

Question 16

The nurse is caring for four cheats. For which cheat should the nurse anticipate treatment with continuous renal replacement therapy (CRRT)?

Accepted Answer

Answer reason: A perioperative MI after CABG strongly suggests impaired cardiac output and instability, and ARF in this setting commonly requires gentle, continuous solute and fluid removal. This aligns with CRRT’s advantage of continuous ultrafiltration and better blood pressure tolerance in ICU patients. In contrast, stage 4 CKD and loss of PD access typically lead to scheduled intermittent hemodialysis planning rather than urgent continuous therapy, and an isolated creatinine rise after vancomycin may be managed by stopping the nephrotoxin and monitoring unless severe complications develop.

Question 17

The nurse is assessing the client following a kidney transplant from a live donor. The nurse should notify the HCP to report a possible complication of urine leakage when which findings are noted?

Accepted Answer

Answer reason: New lower abdominal or incisional discomfort can reflect urine collecting in the pelvis or around the graft/anastomosis. This pattern is more suggestive of a mechanical/postoperative complication than rejection, which more commonly presents with fever, graft tenderness, and declining urine output with rising creatinine. Prompt notification is needed because urine extravasation can rapidly lead to urinoma, infection, and compromised graft function and often requires imaging and possible surgical/urologic intervention.

Question 18

On the third postoperative day following a total laryngectomy, the client’s spouse asks when the client will be able to eat. Which response by the nurse is correct?

Accepted Answer

Answer reason:  After a total laryngectomy, oral intake is typically delayed to protect the surgical site and prevent complications such as pharyngocutaneous fistula while healing occurs. During the early postoperative period, nutrition is provided via enteral feeding (e.g., NG/feeding tube or gastrostomy) until swallowing is evaluated and cleared. Aspiration risk is not the primary long-term issue after a total laryngectomy because the airway is separated from the esophagus via a permanent stoma, making “learning a different way of swallowing to prevent aspiration” misleading. The delay in eating is related to airway/pharyngeal healing rather than postoperative GI paralysis, and long-term permanent gastrostomy feeding is not expected for most patients once healing is adequate.

Question 19

The nurse assesses the client who recently had a lower lobectomy for lung cancer. Findings include dyspnea with respirations at 45 breaths per minute, hypotension, Sao2 at 86% on 10 L close-fitting oxygen mask, trachea deviated slightly to the left, and the right side of the client’s chest not expanding. Which action should be taken by the nurse first?

Accepted Answer

Answer reason: These findings suggest an acute, life-threatening ventilation problem on the right side (absent expansion) with possible mediastinal shift and hemodynamic compromise, which can occur if a postoperative chest drainage system becomes kinked or occluded. A blocked chest tube can rapidly lead to trapped air/blood, worsening hypoxemia and hypotension, so the nurse should immediately assess and correct reversible mechanical causes at the bedside. Increasing oxygen may not correct the underlying failure of lung expansion and delays definitive stabilization. Notifying the provider is appropriate after (or while) initiating immediate corrective assessment, and administering lorazepam is unsafe because it can worsen respiratory drive in a critically hypoxemic patient.

Question 20

The public health nurse is caring for the 10-year-old with hepatitis A. The nurse is instructing the parents to avoid giving their child any medications that are not prescribed. Which is the nurse’s rationale for this instruction?

Accepted Answer

Answer reason: Hepatitis A causes hepatic inflammation, which can reduce the liver’s ability to metabolize and clear many medications. When hepatic clearance is impaired, standard OTC dosing can lead to higher-than-expected serum levels and toxicity, particularly with hepatically metabolized drugs. Avoiding non-prescribed medications reduces the risk of iatrogenic liver injury (e.g., from acetaminophen-containing products) and adverse drug reactions during recovery. Antibiotics are not a routine treatment for viral hepatitis, and nutrition alone does not eliminate medication-related safety risks.

Question 21

The experienced nurse and the new nurse are providing preoperative care for the 4-year-old with Wilms tumor. Which action by the new nurse requires the experienced nurse to intervene?

Accepted Answer

Answer reason: Wilms tumor care prioritizes preventing tumor disruption because manipulation can precipitate rupture and hemorrhage and may promote tumor cell spread. Abdominal palpation is specifically avoided in suspected/known Wilms tumor; assessment focuses on observation, gentle inspection, and monitoring vital signs, pain, and urine output. The other actions reflect appropriate pre-op care: maintaining NPO status as ordered, using therapeutic play with age-appropriate teaching tools, and giving simple, concrete explanations to reduce anxiety. Therefore the assessment action that increases complication risk is the one that requires immediate intervention.

Question 22

The nurse assesses the hospitalized child with severe burn injuries on the lower extremities. Findings include weak distal pulses in the right leg with capillary refill >3 seconds, and the child reports feeling numbness and tingling in the right leg. What should be the nurse’s conclusions regarding this information?

Accepted Answer

Answer reason: Neurovascular compromise after circumferential or severe burns suggests impaired tissue perfusion and possible compartment syndrome, which is limb-threatening. Weak distal pulses, delayed capillary refill, and new paresthesias are red-flag findings indicating reduced arterial flow and/or nerve ischemia that require immediate escalation. Waiting an hour for reassessment risks progression to irreversible ischemic injury. Prompt provider notification is needed for urgent interventions (e.g., escharotomy/fasciotomy) to restore perfusion.

Question 23

The infant is hospitalized after having a respiratory infection and severe diarrhea for 5 days. The child has poor skin turgor, respirations 30 bpm, T 101.3°F (39°C), and watery green stools. The HCP prescribes an antipyretic and IV fluid of DSNS with a potassium additive. What nursing action is most important?

Accepted Answer

Answer reason: Potassium-containing IV fluids should not be started until adequate renal function is confirmed, because impaired excretion can rapidly cause dangerous hyperkalemia and dysrhythmias. An infant with several days of diarrhea and poor skin turgor is at high risk for dehydration and decreased urine output, making this safety check a priority. Fever control and diaper changes are appropriate but do not address the immediate risk of a life-threatening electrolyte complication. A respiratory rate of 30/min is not necessarily distress in an infant and oxygen should be guided by clinical work of breathing and oxygen saturation rather than rate alone.

Question 24

The new nurse places the infant diagnosed with tracheoesophageal fistula under a radiant warmer with the infant’s head elevated at a 30-degree angle. Which statement to the infant’s mother indicates that the new nurse understands the most important reason for this position?

Accepted Answer

Answer reason:  The key principle in tracheoesophageal fistula care is preventing aspiration of saliva and refluxed gastric contents into the airway. Elevating the head decreases gastroesophageal reflux and reduces the likelihood that regurgitated material will enter the trachea through the fistula. This intervention targets the highest-risk complication—aspiration leading to respiratory distress or pneumonia—rather than comfort or digestion. Improving lung expansion may be a minor benefit of head elevation, but aspiration prevention is the primary safety rationale in this condition.

Question 25

The nurse assesses a client with an abdominal aortic aneurysm and is most concerned when the client presents with which of the following?

Accepted Answer

Answer reason: Hypotension indicates developing hemorrhagic shock and is a high-priority danger sign compared with stable or hypertensive presentations. A decreased RBC count supports acute blood loss, making the situation time-critical for rapid emergency response and surgical management. An increased WBC count can occur as a stress/inflammatory response, but the combination with severe pain and hypotension is what most strongly signals rupture risk.

Question 26

A client arriving in the emergency department (ED) is receiving cardiopulmonary resuscitation from paramedics, who are giving ventilations through an endotracheal (ET) tube that they placed in the client’s home. During a pause in compressions, the cardiac monitor shows narrow QRS complexes and a heart rate of 55 beats/minute with a palpable pulse. Which action should the nurse take first?

Accepted Answer

Answer reason: Airway and ventilation must be verified immediately in a patient who was being ventilated via an out-of-hospital endotracheal tube, because unrecognized dislodgement or esophageal placement rapidly causes hypoxia and deterioration. The presence of a palpable pulse and organized narrow-complex rhythm indicates ROSC rather than a shockable arrest rhythm, shifting priorities to post-resuscitation ABCs. Verifying tube placement (e.g., waveform capnography, bilateral breath sounds, chest rise) is the fastest action that prevents a high-risk, reversible cause of impending arrest. Amiodarone is for refractory VF/pulseless VT, not bradycardia with a pulse, and ABGs are diagnostic but not the immediate stabilization step. Atropine could be considered if symptomatic bradycardia persists after ensuring oxygenation/ventilation, but airway confirmation comes first.

Question 27

A nurse is caring for the client who is 2 days postoperative and complaining of severe pain in the left leg. The nurse administers the prescribed morphine sulfate, 2 mg I.V. The client continues to complain of severe pain. The nurse assesses the client’s left leg and finds the extremity cool to touch with absent pulses and a capillary refill greater than 3 seconds. What is the priority action of the nurse?

Accepted Answer

Answer reason: These findings indicate acute neurovascular compromise/arterial occlusion (severe pain unrelieved by opioids, cool limb, absent pulses, delayed capillary refill), which is a limb-threatening postoperative complication requiring immediate intervention. Prompt provider notification is needed for urgent evaluation and possible measures such as loosening restrictive dressings, imaging, anticoagulation, or surgical management to restore perfusion. Delaying care to reassess later risks ischemia and tissue necrosis. Additional opioid dosing can mask worsening ischemia without addressing the cause. Documentation is important but is not the priority over emergent escalation of care.

Question 28

The nurse is preparing the client for discharge. Which of the following discharge instructions should the nurse provide to the client after hip surgery?

Accepted Answer

Answer reason:  Post–hip surgery precautions focus on preventing prosthesis dislocation by avoiding positions that place the hip in high-risk alignment, especially excessive flexion and adduction. Limiting hip flexion to 90 degrees and avoiding leg crossing reduces leverage that can displace the femoral head from the socket, particularly early in recovery. Recommending assistance with shoes reinforces avoiding bending at the waist and hip past the safe range during dressing. Options with lower limits (30 or 60 degrees) are unnecessarily restrictive for standard posterior-approach precautions, while allowing 120 degrees would increase dislocation risk.

Question 29

A client is being discharged from the emergency department after cast application for a tibial fracture. The nurse is aware that the client is at risk for ineffective breathing pattern related to long bone fracture secondary to fat embolus. Based on this diagnosis, which instruction should the nurse provide for this client?

Accepted Answer

Answer reason: A long-bone fracture increases risk for fat embolism syndrome, which can rapidly cause hypoxemia and acute respiratory distress and requires urgent evaluation. Teaching the client to recognize and immediately report early respiratory and systemic warning signs helps prevent delay in treatment and reduces risk of deterioration. The listed symptoms align with typical fat embolism manifestations (respiratory compromise, tachycardia/palpitations, fever, anxiety/apprehension). In contrast, routine deep-breathing is generally helpful for lung expansion but does not address the key discharge priority of recognizing an emergent complication requiring prompt medical attention.

Question 30

A client has a knee-high cast removed 6 weeks after suffering an ankle fracture. Palpation reveals a hard, nontender lump at the fracture site. How should the nurse interpret this finding?

Accepted Answer

Answer reason: At about 6 weeks, a hard, nontender lump at the fracture site is consistent with normal callus formation as the bone consolidates. Malunion is suggested by deformity, abnormal angulation/rotation, functional impairment, or persistent significant pain rather than an isolated painless, hard prominence. Swelling/bruising are soft-tissue findings and would not typically present as a hard, localized bony lump.

Question 31

A 19-year-old client with a mild concussion is discharged from the emergency department. Before discharge, he complains of a headache. When offered acetaminophen, his mother tells the nurse she would like her son to have something stronger. The most appropriate response by the nurse is?

Accepted Answer

Answer reason:  After a concussion, ongoing assessment for neurologic deterioration is a priority, and medications that cloud mentation or alter the neurologic exam increase risk. Opioids can cause sedation, miosis, and respiratory depression, which can mask a declining level of consciousness or other signs of increased intracranial pressure. Acetaminophen is preferred for post–head injury headache because it provides analgesia without affecting platelet function or mental status. A common distractor is focusing on vomiting/ICP; while nausea can matter, the key safety issue is preserving reliable neurologic assessment.

Question 32

The nurse is reviewing a client’s chest X-ray report that states that there are bilateral areas of collapsed alveoli in the bases. The nurse initiated coughing and deep breathing exercises, reinforced the use of the incentive spirometer, and encouraged the client to ambulate in the halls at least twice a day. The nurse implemented these interventions into the plan of care based on what knowledge?

Accepted Answer

Answer reason: Atelectasis reduces the amount of ventilated alveolar surface area available for diffusion, which impairs oxygenation through ventilation-perfusion mismatch. Deep breathing, coughing, incentive spirometry, and early ambulation help re-expand collapsed alveoli, mobilize secretions, and improve ventilation of dependent lung bases. This directly targets the site of oxygen and carbon dioxide transfer at the alveolar-capillary interface. A common distractor is the idea that collapsed alveoli raise oxygen demand; the primary problem is impaired gas exchange and shunting, not increased metabolic demand.

Question 33

A nurse is providing in-home management instruction for a child who is receiving desmopressin acetate (DDAVP) for symptomatic control of diabetes insipidus. What is the most important instruction the nurse to include?

Accepted Answer

Answer reason: Intranasal desmopressin absorption can become unreliable when the nasal mucosa is inflamed or congested, leading to inadequate antidiuretic effect and recurrence of polyuria with dehydration risk. Promptly arranging an alternate route maintains consistent therapy and prevents complications from uncontrolled diabetes insipidus. Self-adjusting the dose based on symptoms is unsafe because desmopressin can cause water retention and hyponatremia if overcorrected. Waiting to give the medication until urine output decreases contradicts scheduled replacement and risks rapid volume depletion.

Question 34

A 6-month-old male with developmental dysplasia of the hip has been treated for the past 6 weeks with a Frejka splint, which maintains abduction through padding of the diaper area. At his follow-up visit, the child's mother reports that she removes the splint when he gets too fussy and that he settles down and sleeps well for several hours after the padding is removed. Which response by the nurse would be most appropriate?

Accepted Answer

Answer reason:  Maintaining continuous hip abduction is essential in developmental dysplasia of the hip to promote proper femoral head positioning and prevent treatment failure. Removing the splint for prolonged periods because of fussiness undermines the therapeutic effect and increases risk of persistent subluxation/dislocation. The best nursing response uses empathy while clearly instructing that the device should remain on, with removal only for brief necessary care such as bathing and diaper changes. The other responses either incorrectly endorse caregiver modification, add nonstandard ROM instructions, or overemphasize calling immediately rather than addressing adherence and proper use first.

Question 35

The nurse is completing discharge teaching with the client who had an exploratory laparotomy. The client has a history of chronic back pain and limited ability to ambulate. The nurse plans for further discharge teaching when the client makes which statement?

Accepted Answer

Answer reason:  Postoperative clients with limited mobility are at ongoing risk for venous thromboembolism after discharge, so prevention measures often must continue at home until ambulation improves. Stopping antiembolic stockings immediately on discharge reflects misunderstanding of a key complication-prevention intervention, especially with this client’s limited ability to ambulate. In contrast, nutrition supporting wound healing and using cold therapy for comfort can be appropriate if aligned with provider instructions. The spirometer statement is not a discharge-teaching red flag; the priority education gap here is thrombosis prevention.

Question 36

A 17-year-old primigravida with severe hypertension of pregnancy has been receiving magnesium sulfate I.V. for 3 hours. The latest assessment reveals deep tendon reflexes (DTR) of +1, blood pressure of 150/100 mm Hg, a pulse of 92 beats/minute, a respiratory rate of 10 breaths/minute, and urine output of 20 ml/hour. Which action would be most appropriate?

Accepted Answer

Answer reason: Magnesium sulfate toxicity risk increases when renal clearance is reduced, and classic early warning signs include depressed deep tendon reflexes, respiratory depression, and oliguria. This client has RR 10/min and urine output 20 mL/hr, both concerning for impending toxicity and impaired excretion, with DTRs already diminished. The safest immediate nursing action is to stop the infusion to prevent progression to apnea and cardiac arrest while preparing to notify the provider and administer calcium gluconate per protocol. Options to increase or continue the infusion ignore escalating toxicity indicators and create an avoidable life-threatening complication.

Question 37

A client presents to the emergency department (ED) via ambulance with SOB for the past 3 days. After spending 4 hours in the ED, the client is admitted to the intensive care unit (ICU) with pulmonary edema requiring intubation and ventilation. The ED nurse reports to the ICU nurse that a Foley catheter was placed and that the client has had a total of 25 mL of urine output. The labs from the ED reveal (1) BG of 300, (2) BUN of 100, and (3) creatinine of 5.0. The client has a medical history of CAD, CHF, diabetes, COPD, and asthma. What is the most likely cause of the client’s low urine output?

Accepted Answer

Answer reason: Marked oliguria with very elevated BUN and creatinine indicates significant renal dysfunction rather than an isolated bladder/foley issue. The presentation with pulmonary edema and known CHF supports reduced effective renal perfusion (prerenal azotemia) from low cardiac output, which can rapidly drop urine output. Long-standing diabetes also predisposes to chronic kidney disease, making the kidneys less able to compensate during an acute perfusion insult (acute-on-chronic kidney injury). A common distractor is dehydration, but pulmonary edema and likely volume overload make dehydration unlikely as the primary driver here.

Question 38

The protrusion of an internal organ through a wound or surgical incision is referred to as ?

Accepted Answer

Answer reason: It differs from dehiscence, which is separation of wound edges without organ protrusion. Serosanguineous describes the character of wound drainage (thin, watery, blood-tinged) rather than a structural wound failure. Exuded refers generally to drainage/oozing and does not specifically indicate organ protrusion through an incision.

Question 39

A nurse is caring for a patient who recently had surgery to set a fracture and now has his extremity casted. Which of these nursing examinations is not typically utilized to assess for compartment syndrome?

Accepted Answer

Answer reason:  Compartment syndrome is primarily detected by assessing ischemia and rising compartment pressure, classically reflected by severe pain out of proportion, pain with passive stretch, and evolving neurovascular compromise distal to the cast. A focused neurovascular check therefore emphasizes circulation (pulses, cap refill, temperature, color) and neurologic status (sensation, paresthesias), with passive stretch being a particularly sensitive early sign. Strength testing is not typically relied on as a screening exam because motor weakness is often a later finding and may be confounded by pain, immobilization, postoperative effects, or patient effort. A common pitfall is overreliance on distal pulses; they can remain present despite dangerous compartment pressures, so combining circulation, sensation, and passive-stretch pain is more clinically useful.

Question 40

The pediatric nurse is caring for a 5-year-old client with cystic fibrosis. Which of the following assessment findings is most concerning?

Accepted Answer

Answer reason: Temperature of 101 F (38.3 C) Children with cystic fibrosis are at high risk for acute pulmonary infection and rapid respiratory decline, so new fever is a key early warning sign. A temperature of 38.3 C suggests an infectious exacerbation that can increase airway inflammation, mucus plugging, and worsen oxygenation, requiring prompt evaluation and treatment. A productive cough and bulky, loose stools are common baseline manifestations of CF (chronic airway mucus and pancreatic insufficiency) and are not inherently emergent without other red flags. A respiratory rate of 29 can be within expected range for a 5-year-old and is less specific than fever for an acute complication in CF. Prioritizing infection risk helps prevent progression to significant hypoxemia and respiratory failure.

Question 41

When discussing risk factor modification for a client with a 4 cm abdominal aortic aneurysm, the nurse should focus client teaching on which modifiable risk factor?

Accepted Answer

Answer reason: Teaching focused on controlling hypertension (med adherence, home BP monitoring, diet/exercise, follow-up) directly targets a major modifiable contributor to aneurysm growth. Male sex and Marfan syndrome are important risk factors but are not modifiable through teaching. Prior abdominal trauma may be historical and not typically a changeable ongoing risk compared with optimizing BP control.

Question 42

A 57-year-old recovering from a cardiac catheterization is being assessed. The site used was the left groin. The nurse should immediately report which finding?

Accepted Answer

Answer reason: A cool, mottled extremity indicates acute limb ischemia from arterial occlusion (e.g., thrombosis/embolus, arterial spasm, or access-related complication) and requires immediate provider notification to prevent tissue loss. The other findings are expected/benign in this context: mild pain can be normal, capillary refill in the opposite hand is irrelevant to the access limb, and the listed vital signs are stable without signs of shock or bleeding. Rapid assessment of distal pulses, color, temperature, sensation, and movement is critical while escalating care.

Question 43

A nurse prepares to discontinue an IV line on a client on the first postop day after surgery. What action is most important for the nurse to perform before discontinuing the line?

Accepted Answer

Answer reason: Maintaining hydration and hemodynamic stability after surgery requires ensuring the client can meet fluid needs without IV support. On the first postoperative day, the IV line is often the primary safeguard against inadequate intake, nausea/vomiting, or delayed return of GI function. Confirming that the client is tolerating sufficient oral fluids helps prevent dehydration, hypotension, and electrolyte problems once the IV is removed. Urine output is an important trend but can lag behind current intake and does not by itself confirm the client can maintain hydration going forward; cleaning the site is done during removal but does not address the major physiologic risk.

Question 44

A 63-year-old female patient has been admitted with severe abdominal pain and suspected gastritis. The patient is currently awaiting further diagnostic tests. Which of the following nursing actions aligns best with the initial interventions for a patient with gastrointestinal complications?

Accepted Answer

Answer reason: With severe abdominal pain and an undifferentiated GI complaint, initial nursing care prioritizes preventing aspiration/worsening inflammation and preparing for potential procedures (e.g., imaging or endoscopy) that require nothing by mouth. Holding oral intake also reduces gastric stimulation and helps avoid exacerbating nausea/vomiting or bleeding if present. IV fluids support intravascular volume and hydration when oral intake is unsafe or restricted and help mitigate dehydration from vomiting or poor intake. Giving milk or an OTC antacid can be inappropriate before the cause is clarified and may delay or complicate diagnostic evaluation, while deep breathing may help coping but does not address immediate physiologic risk.

Question 45

In caring for the preterm infant, which complication is thought to be a result of high arterial blood oxygen level?

Accepted Answer

Answer reason: This makes oxygen toxicity a classic risk factor for this eye complication in premature neonates, especially with uncontrolled supplemental oxygen. By contrast, necrotizing enterocolitis is more strongly linked to intestinal immaturity, ischemia, and enteral feeding factors rather than hyperoxemia. IVH is primarily related to fragile germinal matrix vessels and fluctuations in cerebral blood flow, not high PaO2 as the key driver. Care focuses on tight oxygen saturation targets and careful monitoring to reduce this preventable complication.

Question 46

Which preterm infant should receive gavage feedings instead of bottle feeding?

Accepted Answer

Answer reason: A sustained RR of 70/min indicates tachypnea and increased work of breathing, making bottle feeding unsafe because the infant cannot reliably pause breathing to swallow. Gavage feeding allows nutrition delivery while minimizing energy expenditure and decreasing the likelihood of choking, desaturation, and aspiration. By contrast, nonnutritive sucking on a pacifier supports oral-motor development, and brief gagging with tube insertion can occur without indicating inability to orally feed if respiratory status is stable. Normal temperature and a heart rate around 149/min suggest physiologic stability rather than a need to avoid oral feeds.

Question 47

A patient is 2 hours status post paracentesis. After the unlicensed assistive personnel (UAP) assisted the patient out of bed, the UAP reports to the nurse, “The patient got dizzy and stumbled while I was helping with transfer to the chair.” What intervention should the nurse perform first?

Accepted Answer

Answer reason: Post-paracentesis patients are at risk for fluid shifts and hypotension, and new dizziness during transfer may indicate an acute complication requiring rapid bedside evaluation. The nurse’s first action is to directly assess for airway/breathing/circulation stability, orthostatic symptoms, bleeding, and injury from a near-fall to determine immediate safety needs. Provider notification and consults are secondary steps that depend on assessment findings and do not address the immediate risk. Delegating vital signs alone to the UAP delays the nurse’s clinical judgment when an instability or fall risk may be present.

Question 48

The nurse is caring for a client newly admitted to the mental health unit with bulimia nervosa. Which client statement requires immediate follow-up?

Accepted Answer

Answer reason: Acute dizziness signals possible hemodynamic instability or dangerous electrolyte abnormalities, which are high-risk complications in bulimia due to vomiting, laxative/diuretic misuse, and dehydration. This symptom can reflect orthostatic hypotension and/or hypokalemia-related dysrhythmias, requiring prompt assessment of vital signs, hydration status, and cardiac/electrolyte evaluation. Compared with oral sores, bloating, or poor sleep, dizziness has the greatest immediate potential to indicate impending syncope or cardiac compromise. Immediate follow-up helps prevent falls and rapidly identifies life-threatening complications.

Question 49

The nurse has received information about assigned clients. Which of the following clients has an increased risk for hypocalcemia?

Accepted Answer

Answer reason: This complication can appear within 24–48 hours and may present with perioral tingling, muscle cramps, tetany, and positive Trousseau/Chvostek signs, with potential progression to laryngospasm or seizures. Viral gastroenteritis more commonly causes volume depletion and potassium/acid–base disturbances rather than an isolated calcium drop. Breast cancer bone metastases are classically associated with hypercalcemia from osteolysis, and SIADH primarily causes dilutional hyponatremia.

Question 50

All of the following are common signs and symptoms of phlebitis except?

Accepted Answer

Answer reason: These reflect an inflammatory process and possible spread along the vessel rather than loss of vascular integrity. Frank bleeding is more consistent with catheter dislodgement, inadequate occlusion after removal, coagulopathy, or anticoagulant effect, not typical phlebitis. A common distractor is edema, which can occur with both phlebitis and infiltration, but warmth and redness support inflammation rather than leakage into tissue.

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