Question 1

The nurse is planning care for a client who underwent a craniotomy for removal of a brain tumor 8 hours ago. Which of the following would be a priority for the nurse to include in the plan of care?

Accepted Answer

Answer reason: Monitoring the surgical dressing for amount and character of drainage helps identify hemorrhage or CSF leak early and prompts urgent provider notification and interventions. Although urine output is an important perfusion indicator, it is less specific to the most dangerous neurosurgical complication in the first hours after surgery. Lower-extremity edema and premeal glucose checks do not address the most immediate, procedure-specific postoperative risk.

Question 2

The nurse is providing home care instructions to the parents of a 10-year-old child with hemophilia. Which sport activity should the nurse suggest for this child?

Accepted Answer

Answer reason: Low-impact, noncontact exercise supports cardiovascular fitness and muscle strength while reducing the chance of falls and blows that can trigger hemorrhage. This option best fits because it provides conditioning with minimal joint stress and very low risk of contact injury. In contrast, sports like soccer, basketball, and field hockey involve frequent collisions, rapid pivots, and falls, increasing risk for hemarthrosis and serious bleeding. Teaching should emphasize protective activity choices to prevent complications and preserve joint function.

Question 3

The nurse is caring for a client taking tamoxifen for breast cancer. Which client statement is most concerning and a priority to report to the health care provider?

Accepted Answer

Answer reason: " Tamoxifen has estrogen-agonist effects on the endometrium, increasing risk for endometrial hyperplasia and cancer, so abnormal uterine bleeding requires prompt evaluation. Heavy or unusual vaginal bleeding can indicate a serious complication rather than an expected nuisance side effect. Hot flashes and decreased libido are common and generally managed symptomatically without urgent workup. Cold-like symptoms are nonspecific and are not a classic high-priority adverse effect of this medication compared with abnormal uterine bleeding.

Question 4

Which of the following complications of an abdominal aortic repair is indicated by detection of a hematoma in the perineal area?

Accepted Answer

Answer reason: Retroperitoneal hemorrhage can dissect along fascial planes to the groin and perineum, making this a key sign of a leak/rupture at or near the repair. This represents an urgent postoperative complication because concealed bleeding may progress before overt hypotension is noted. A hernia or stage 1 pressure injury would not explain acute dependent ecchymosis/hematoma, and “rapid expansion” is less specific than evidence of actual bleeding/rupture.

Question 5

The nurse provides care for a patient who has just returned from an endovascular repair of an abdominal aortic aneurysm (AAA). Which assessment should the nurse perform first?

Accepted Answer

Answer reason: After endovascular AAA repair, the most time-sensitive risk is impaired distal perfusion from arterial occlusion/embolization or access-site thrombosis. Checking lower-extremity pulses immediately helps detect acute limb ischemia early, when rapid intervention can prevent tissue loss. Incision/groin bleeding is important but typically becomes evident through vital-sign instability and visible hematoma and is not as specific for the key vascular complication of this procedure. BUN trends and pain/nausea assessment are appropriate postoperative checks but do not take priority over confirming adequate circulation to the legs.

Question 6

The nurse provides care for a patient who is postoperative for a thyroidectomy. Which clinical data indicates a need for immediate action by the nurse?

Accepted Answer

Answer reason: Airway compromise is the highest-priority, time-critical postoperative complication after thyroidectomy due to neck hematoma or laryngeal edema causing upper airway obstruction. Stridor is a sign of significant airway narrowing and can rapidly progress to complete obstruction, requiring immediate assessment, activation of emergency response, and preparation for airway management. By contrast, mild tachycardia can be due to pain/anxiety, and incisional pain is expected postoperatively when not accompanied by airway or bleeding signs. The reported calcium is within normal limits, whereas hypocalcemia-related tetany is typically associated with lower calcium levels and neuromuscular irritability rather than acute stridor.

Question 7

The nurse is caring for a client with Guillain-Barré syndrome (GBS). The nurse plans on taking which priority action?

Accepted Answer

Answer reason: GBS can cause rapidly progressive ascending neuromuscular weakness that may involve the diaphragm and intercostal muscles, making respiratory failure the most immediate life-threatening complication. Frequent respiratory assessment (rate/effort, ability to clear secretions, and trending vital capacity/negative inspiratory force when available) allows early recognition of impending ventilatory failure and timely escalation to airway support. IVIG is an important disease-modifying therapy, but it does not replace ongoing airway/ventilation surveillance when weakness can progress over hours to days. Passive ROM supports mobility and prevents contractures but is not priority over airway/breathing. Autonomic instability can occur in GBS, but autonomic dysreflexia is classically associated with spinal cord injury above T6 and is less directly applicable here than respiratory monitoring.

Question 8

A client with a history of chronic kidney disease was recently admitted to the hospital due to worsening kidney function. The client performs peritoneal dialysis (PD) at home. During physical assessment and review of new laboratory values, the nurse would correctly identify which finding as a potential complication of PD?

Accepted Answer

Answer reason: Leukocytosis supports an acute infectious/inflammatory process, and poor dialysate outflow suggests catheter obstruction, constipation-related flow impairment, or fibrin clogging—findings that warrant prompt evaluation and intervention. Together these findings are more specific for a PD-related complication than baseline CKD abnormalities. In contrast, elevated creatinine/BUN and anemia/hypertension reflect chronic renal insufficiency and volume/erythropoietin issues rather than a PD-specific acute complication.

Question 9

The nurse is caring for a client who is receiving multiple chemotherapeutic medications to treat breast cancer. Which of the following statements by the client would require immediate follow-up?

Accepted Answer

Answer reason: " Chemotherapy commonly causes myelosuppression, and neutropenia can make infection present subtly but progress rapidly to sepsis. Chills/feeling febrile is a red-flag symptom that warrants immediate assessment of temperature, vital signs, and prompt evaluation for febrile neutropenia with urgent provider notification. In contrast, mucositis, nausea/vomiting, and intermittent diarrhea are expected adverse effects that usually require symptom management unless severe, dehydrating, or associated with fever or bleeding. The priority is early detection and treatment of infection because it is the most time-sensitive, life-threatening complication in this context.

Question 10

The nurse is providing postoperative teaching for a client who underwent phacoemulsification of a cataract in the left eye. Which of the following information should the nurse include?

Accepted Answer

Answer reason: ” Post–cataract surgery teaching prioritizes preventing increases in intraocular pressure to protect the surgical site and reduce risk of hemorrhage or wound dehiscence. Bending forward and Valsalva/straining during defecation can significantly raise intraocular pressure, so clients are instructed to avoid these and use stool softeners as needed. Deep breathing and coughing can also raise intraocular pressure and are not a routine goal after eye surgery unless indicated for another condition. Rubbing the eye is contraindicated because it can disrupt healing and increase infection risk.

Question 11

The nurse in the pediatric clinic instructs the parent of a preschool client diagnosed with asthma about preventative care. Which statement by the parent indicates to the nurse that further teaching is necessary?

Accepted Answer

Answer reason: " Asthma prevention focuses on minimizing exposure to triggers such as dust mites, which accumulate in bedding and upholstered surfaces and worsen with disturbed, older, or less-controlled sleep environments. Sleeping on a top bunk often increases exposure to dust that settles higher and may involve mattresses/linens without allergen-proof encasings, making trigger control less reliable when away from home. In contrast, zippered pillow/mattress covers are a standard dust-mite reduction strategy, and changing clothes after outdoor play helps reduce pollen exposure. Wearing a mask while vacuuming reduces inhalation of aerosolized dust during cleaning, which is a reasonable trigger-avoidance measure.

Question 12

A client with a testicular malignancy undergoes a radical orchiectomy. In the immediate postoperative period the nurse should particularly assess the client for?

Accepted Answer

Answer reason: After radical orchiectomy, occult hemorrhage or inadequate fluid replacement can present first as decreasing hourly output before other signs become pronounced. Monitoring output also helps identify early urinary retention related to anesthesia, opioids, or perioperative swelling. Pain and nausea are expected postoperative symptoms and require treatment, but they are less specific for life-threatening complications than changes in output.

Question 13

The goal of nursing care for a client with acute myeloid leukemia (AML) is to prevent?

Accepted Answer

Answer reason: Nursing priorities focus on preventing and rapidly detecting bleeding (e.g., bleeding precautions, avoiding IM injections/rectal temps, monitoring for hematuria, melena, petechiae, and neuro changes suggesting intracranial bleeding). This complication is more immediate and common than end-organ failures listed, and it can deteriorate quickly with minimal warning. While tumor lysis can contribute to renal injury during treatment, the most direct overarching nursing goal across AML care is bleeding prevention and safety.

Question 14

During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client’s?

Accepted Answer

Answer reason: Tight hemodynamic control reduces bleeding risk while maintaining adequate cerebral perfusion to the ischemic penumbra. Therefore, frequent monitoring and treatment of elevated readings is the primary vital-sign control priority in the first 24 hours. Pulse, respirations, and temperature are important to monitor, but they are not the main modifiable factor most directly linked to post-thrombolysis bleeding complications.

Question 15

The nurse has instructed the client about the correct positioning of his leg and hip following hip replacement surgery. Which of the following statements indicate that the client has understood these instructions?

Accepted Answer

Answer reason: Bending forward to tie shoes commonly forces the hip into excessive flexion and is a classic movement restriction taught in post-op hip precautions. Crossing the legs increases hip adduction and is contraindicated even if the knees are straight. Chair choice matters because low, soft chairs increase hip flexion; patients should use a firm, higher-seated chair, and early ambulation is encouraged rather than avoided for months to reduce complications like DVT and deconditioning.

Question 16

A nurse is caring for a client who is diagnosed with tuberculosis. To achieve the desired outcome, which is the best nursing action?

Accepted Answer

Answer reason: Tuberculosis requires prolonged multidrug treatment to eradicate organisms and prevent relapse, treatment failure, and development of drug-resistant TB. Emphasizing strict adherence directly supports the primary outcome of cure and reduced transmission risk. Interruptions in therapy are a leading cause of multidrug-resistant TB and ongoing infectiousness, making this a high-priority nursing action. The other options do not address the central safety/complication risk; nutrition and activity may be supportive, but they do not prevent resistance or ensure effective disease control.

Question 17

The nurse is preparing a client for discharge the day after a kidney stone lithotripsy. Which statement made by the client would require further education?

Accepted Answer

Answer reason: Routine restriction of dietary calcium is generally not recommended because normal calcium intake can bind intestinal oxalate and lower urinary oxalate, whereas low calcium diets can increase stone risk and adversely affect bone health. Increasing fluids is appropriate, but coupling it with blanket calcium restriction reflects a common misconception and indicates a need for further education. Reducing sodium is evidence-based because high sodium intake increases urinary calcium excretion and promotes calcium stone formation. Mild discomfort can be expected, though severe pain, fever, or inability to void should prompt evaluation for complications such as obstruction or infection.

Question 18

The nurse should notify the physician immediately of which of the assessment findings?

Accepted Answer

Answer reason: g., cervical/vaginal laceration) rather than uterine atony, and this can rapidly progress to postpartum hemorrhage. A steady trickle is a concerning pattern because it may continue unabated and not respond to fundal massage/uterotonics. This finding warrants prompt provider evaluation for inspection and repair and assessment of hemodynamic stability. In contrast, small clots can be expected early postpartum, and a musty lochia odor is not as concerning as a foul, offensive odor with fever or uterine tenderness.

Question 19

A client is to be discharged 12 hours after delivery. The nurse should delay the discharge and notify the physician if which of the following is observed?

Accepted Answer

Answer reason: A total of 240 mL over 12 hours is low and suggests oliguria or incomplete bladder emptying, warranting evaluation for urinary retention, dehydration, or evolving complications. By contrast, moderate lochia rubra and a firm fundus at the umbilicus are expected findings at about 12 hours postpartum. Mild postpartum bradycardia (e.g., pulse in the low 60s) can be a normal physiologic response after delivery when other findings are stable.

Question 20

The nurse is caring for a client who is one-day post-operative following a total laryngectomy with a tracheostomy placement. When providing tracheostomy care, which assessment finding requires immediate follow-up?

Accepted Answer

Answer reason: Subcutaneous emphysema after a new tracheostomy suggests air leaking into subcutaneous tissues from malposition, tracheal injury, or disrupted airway seal, which can rapidly progress to airway compromise. Crepitus around the stoma/neck is an abnormal, high-risk finding that warrants immediate assessment of tube position and ventilation status and prompt provider/rapid response notification as needed. In contrast, mild blood-tinged secretions, localized stoma edema, and expected incisional soreness can occur early postoperatively and are typically monitored unless severe or worsening. The immediacy is driven by the potential for sudden respiratory deterioration.

Question 21

The nurse is caring for a client with heart failure who has a magnesium level of 1.4 mg/dL. The nurse should?

Accepted Answer

Answer reason: Hypomagnesemia (1.4 mg/dL; low) increases myocardial irritability and predisposes to dysrhythmias, especially in a client with heart failure who may also be on diuretics or digoxin. The safest immediate nursing action is enhanced cardiac monitoring/assessment for rhythm changes and related symptoms (palpitations, dizziness, syncope). Options focused on avoiding magnesium-rich foods or limiting intake are inappropriate because the problem is deficiency, not excess. Antacids with phosphate do not address low magnesium and can complicate electrolyte balance.

Question 22

The nurse reviews telephone messages in the pediatric clinic. Which message will the nurse return first?

Accepted Answer

Answer reason: Newborn umbilical findings must be triaged for early infection because omphalitis can progress rapidly to systemic illness. Moistness at the base with surrounding erythema suggests abnormal inflammation/infection and warrants prompt assessment and parent teaching (keep clean/dry, monitor for spreading redness, foul odor, fever, poor feeding). In contrast, an exaggerated startle (Moro) reflex when the crib is bumped is expected in a 2-day-old, and yellowish exudate on a circumcision site is commonly normal granulation during healing. One stool per day for a formula-fed 4-day-old can be within normal variation if the infant is feeding well and not showing dehydration or distress.

Question 23

The nurse is caring for four newborns during their shift in the unit. After performing an assessment, which newborn should the nurse see first?

Accepted Answer

Answer reason: Failure to pass meconium within the first 24–48 hours is a red flag for possible intestinal obstruction or motility disorder and can quickly progress to vomiting, abdominal distention, dehydration, and electrolyte imbalance. This finding requires prompt assessment of abdominal exam, feeding tolerance, emesis (especially bilious), and need for urgent provider notification/diagnostics. In contrast, a bilirubin of 3 mg/dL at day 3 is low and consistent with expected physiologic jaundice patterns, and a positive Babinski reflex is normal in young infants due to immature corticospinal tracts. Passing meconium at 3 hours is reassuring and indicates normal GI patency.

Question 24

The nurse is caring for a client who is six hours post-operative from a laparoscopic appendectomy. Which of the following findings requires immediate follow-up?

Accepted Answer

Answer reason: Postoperative tachycardia can be an early sign of hemorrhage, hypovolemia, uncontrolled pain, pulmonary embolus, or developing sepsis and therefore warrants prompt assessment and intervention. At 6 hours after abdominal surgery, a sustained heart rate >100 is not an expected benign finding and should trigger evaluation of bleeding (incision/drains, abdominal distention), vital-sign trends, urine output, and oxygenation. In contrast, mild elevation in temperature can occur from atelectasis or the inflammatory response, and hypoactive bowel sounds are common early after anesthesia. Moderate incisional pain is expected and should be treated, but it is less immediately life-threatening than unexplained tachycardia and does not by itself indicate an acute complication.

Question 25

The nurse in a hematology clinic is evaluating clients’ risk for pernicious anemia. At highest risk for pernicious anemia is the?

Accepted Answer

Answer reason: Bariatric procedures that reduce or bypass the stomach can markedly decrease intrinsic factor production and limit B12 absorption, making this risk especially high. In contrast, heavy menstrual bleeding and poor nutrition in pregnancy more commonly lead to iron and/or folate deficiency rather than intrinsic-factor–related B12 malabsorption. Irradiation may suppress marrow and cause cytopenias, but it is not the classic mechanism that specifically drives intrinsic-factor deficiency and pernicious anemia.

Question 26

The nurse is caring for a client following a bedside thoracentesis. Which action should the nurse take immediately following the procedure?

Accepted Answer

Answer reason: Immediately after thoracentesis, the priority is early detection of acute complications that can rapidly impair ventilation and oxygenation, especially pneumothorax and re-expansion pulmonary edema. A focused respiratory assessment (work of breathing, breath sounds, SpO2, symmetry, and vital signs) is the fastest way to identify deterioration and guide urgent escalation. A chest x-ray is often ordered after the procedure, but it does not replace the need for immediate bedside assessment and should not delay recognition of respiratory compromise. Specimen labeling and breathing instruction are important tasks, but they are not the first action when prioritizing airway and breathing safety.

Question 27

The telehealth nurse is teaching a client who was exposed to poison ivy. Which of the following information should the nurse include?

Accepted Answer

Answer reason: Poison ivy causes allergic contact dermatitis from urushiol oil, and early decontamination reduces the amount absorbed and can lessen severity. Prompt washing with soap and water (and cleaning under nails, clothing, and gear) helps remove the resin before it binds to the skin. Heat can worsen pruritus and inflammation, so hot compresses are not recommended; cool compresses and topical anti-pruritics are more appropriate. This is not an infection that “spreads” via creams; the rash spreads from delayed reactions or continued exposure to contaminated items. Tetanus prophylaxis is not routinely indicated for plant dermatitis unless there is a relevant wound with immunization risk factors.

Question 28

The nurse is planning care for a client receiving continuous renal replacement therapy (CRRT). Which of the following actions should the nurse include in the client's plan of care?

Accepted Answer

Answer reason: Frequent lung sound assessment helps detect early crackles, increasing work of breathing, and worsening oxygenation so ultrafiltration goals and hemodynamic support can be adjusted promptly. ACE inhibitors like lisinopril are often held in acute kidney injury/CRRT due to hypotension risk and altered renal perfusion. Metabolic panels must be monitored frequently during CRRT because electrolytes and acid-base status can change rapidly, so stopping labs would increase risk.

Question 29

A nurse is caring for a client who sustained a closed fracture of the right tibia and fibula following a fall. The client's leg is immobilized with a cast. On the second day after the injury, the client reports increasing pain, numbness, and tingling in the affected leg. The nurse observes the leg is swollen and tense with pale skin color. What should the nurse suspect and prioritize as the appropriate action?

Accepted Answer

Answer reason: The key principle is that rising tissue pressure within a closed fascial compartment compromises perfusion and nerve function, creating a limb-threatening emergency. Disproportionate increasing pain with paresthesias, a tense swollen extremity, and pallor after casting strongly indicates evolving neurovascular compromise rather than expected edema. The immediate priority is to relieve external constriction (bivalve/split or remove the cast per protocol and obtain urgent provider evaluation) to prevent ischemia, necrosis, and potential permanent deficits. Infection typically presents with fever, warmth, redness, and drainage rather than a tight, pale, tense limb with numbness. Elevation may be used cautiously, but it does not correct the pressure problem and can delay definitive decompression if relied on as the main action.

Question 30

The nurse enters a client's room for the first time during the shift and realizes that the IV fluids are infusing 100 mL/hr faster than the prescribed rate. Which of the following actions should the nurse take first?

Accepted Answer

Answer reason: The nurse’s first priority is to assess for harm by checking vital signs and lung sounds for early signs such as hypertension, tachycardia, crackles, decreased oxygenation, or respiratory distress. This assessment guides the urgency of interventions (e.g., stopping/adjusting fluids, oxygen, escalation of care) and provides a baseline for monitoring. Adjusting the rate is important but comes after rapid assessment to ensure the client is stable. Provider notification and incident reporting occur after immediate patient assessment and stabilization.

Question 31

The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300mL. The nurse should give priority to?

Accepted Answer

Answer reason: Priority nursing action is to escalate care promptly while continuing close assessment for shock (vital signs, level of consciousness, skin perfusion) and ensuring the drainage system remains intact. Routine repositioning does not address the underlying risk, and attempting to “milk” the tube is generally avoided because it can create excessive negative pressure and tissue trauma. Adjusting the IV infusion rate without orders does not treat the likely cause and can delay definitive management.

Question 32

At PHC level, a women who complains of spotting following IUCD insertion should be advised?

Accepted Answer

Answer reason: Initial primary care advice is supportive management with analgesia and observation while screening for danger signs (heavy bleeding, severe pain, fever, foul discharge, syncope) that would require urgent referral. Routine antibiotics are not indicated unless there is evidence of pelvic infection or high STI risk. Removal is unnecessary for simple spotting and is reserved for complications such as expulsion, perforation, uncontrolled bleeding, or confirmed infection not responding to management.

Question 33

Following a liver biopsy, the highest priority assessment of the patient's condition is to check for?

Accepted Answer

Answer reason: Priority assessment focuses on detecting internal hemorrhage via vital signs (tachycardia, hypotension), decreasing hematocrit, increasing abdominal pain/distention, and signs of shock. While pain is expected and should be managed, it is not as immediately dangerous as occult bleeding. Respiratory changes or pulmonary edema are not the most common priority concerns compared with post-procedure hemorrhage.

Question 34

The nurse should teach a client that a normal local tissue response to radiation is?

Accepted Answer

Answer reason: Early, expected reactions include erythema (a sunburn-like appearance) and mild warmth/tenderness confined to the treatment field. Pustule formation suggests infection rather than an expected radiation effect and warrants evaluation. Sloughing of multiple layers indicates severe skin breakdown (moist desquamation) and is not considered a normal/expected response. Skin atrophy is more consistent with late/chronic effects rather than an immediate normal local response.

Question 35

The nurse is aware that a neonate of a mother with diabetes is at risk for what complication?

Accepted Answer

Answer reason: After birth, the maternal glucose supply abruptly stops while the newborn’s insulin level may remain high, causing a rapid drop in blood glucose. This makes early monitoring and prompt feeding (or IV dextrose if symptomatic) key to preventing neurologic injury. The other options are not the classic immediate, high-frequency metabolic complication expected in this population compared with low glucose.

Question 36

A nurse is caring for a client who had an insertion of radium for cancer of the cervix. For what radium reaction should the nurse assess the client?

Accepted Answer

Answer reason: This manifests as erythema, irritation, and progressing to excoriation/ulceration, making focused assessment of the treated area and surrounding skin essential. Pain and nausea can occur with cancer therapy but are nonspecific and not the characteristic local reaction being tested for this modality. Restlessness is not a typical direct radiation reaction and would prompt evaluation for anxiety, discomfort, or other complications rather than being expected.

Question 37

A nurse is caring for a client who had an insertion of radium for cancer of the cervix. For what radium reaction should the nurse assess the client?

Accepted Answer

Answer reason: This reaction presents as erythema, soreness, and excoriation, and early identification helps prevent worsening ulceration and infection. Nausea can occur with radiation but is less characteristic of localized cervical radium placement than local tissue injury. Pain and restlessness are nonspecific findings and do not target the most typical complication of radium insertion.

Question 38

A nurse is caring for a client who is 24 hours postoperative cholecystectomy. Upon assessment, the nurse notes that the T-tube has drained 800 mL of green-brown drainage. Which would be the best action done by the nurse?

Accepted Answer

Answer reason: Excessive biliary drainage from a T-tube soon after cholecystectomy can indicate a complication such as bile leak, obstruction, or hemorrhage-related increased output and requires prompt provider evaluation. An output of 800 mL in 24 hours is higher than expected for typical postoperative bile drainage and warrants escalation rather than routine charting. Clamping a T-tube without an order can precipitate biliary obstruction and worsening pain/jaundice and is unsafe. Monitoring vital signs is appropriate supportive assessment, but it does not address the abnormal finding as the priority action; the provider must be notified for further orders and evaluation.

Question 39

The nurse is screening clients for those at increased risk for developing neutropenia. At highest risk for developing neutropenia is the client who?

Accepted Answer

Answer reason: This makes infection risk highest during chemotherapy cycles, particularly around the expected nadir period when ANC falls most. Radiation limited to the neck is less likely to significantly suppress marrow because major hematopoietic sites (pelvis, long bones, sternum) are not in the field. Cyanocobalamin treats B12 deficiency and would be expected to improve, not worsen, cytopenias; untreated CLL more often causes lymphocyte abnormalities unless marrow failure is advanced.

Question 40

The nurse is planning care for a 6-year old client with acute glomerulonephritis. Which of the following interventions should the nurse include in the client's plan of care?

Accepted Answer

Answer reason: Daily weights are the most sensitive, noninvasive indicator of fluid status changes and help detect worsening fluid overload early. Calcium restriction is not a standard priority in this condition; sodium/fluid restriction and monitoring are more relevant. Norepinephrine is not indicated unless there is severe shock, and frequent ambulation does not address the primary immediate risk of fluid volume excess.

Question 41

A 37-year-old client is scheduled for an induction at 38 weeks gestation for gestational diabetes. An IV is placed and the client is started on Pitocin. Which parameters are priority for the nurse to monitor while the client is having oxytocin infused?

Accepted Answer

Answer reason: Continuous assessment of contraction frequency/strength along with fetal heart rate pattern is the most direct way to detect early fetal intolerance and excessive stimulation. These findings guide immediate interventions such as stopping the infusion, repositioning, giving IV fluids, and oxygen as ordered. Maternal pain, cervical change, and IV site checks are important but do not identify the most time-critical complication of oxytocin administration as reliably as uterine activity plus fetal response.

Question 42

The nurse is caring for a client with peritoneal dialysis. The client reports an outflow of only one-half of the dialysate solution that was dwelled. The nurse should instruct the client to do which of the following?

Accepted Answer

Answer reason: In peritoneal dialysis, decreased outflow is most commonly caused by catheter outflow obstruction from constipation, which can mechanically compress or kink the catheter and impair drainage. Promoting a bowel movement relieves colonic distention and often restores normal dialysate return without introducing additional risk. Stripping the catheter can create excessive negative pressure and may damage the catheter or dislodge clots, and adding more dialysate can worsen discomfort and does not correct the obstruction. Applying heat is not a standard first-line intervention for poor outflow and may delay addressing the likely cause.

Question 43

The nurse cares for a client who had a liver transplant 48 hours ago. It would be a priority for the nurse to notify the healthcare provider (HCP) if the client has?

Accepted Answer

Answer reason: In the first 48 hours after a liver transplant, abrupt or progressive elevations in transaminases can signal graft dysfunction from acute rejection, hepatic artery thrombosis, or ischemia-reperfusion injury and require urgent evaluation. This finding reflects hepatocellular injury and may precede rapid clinical deterioration, so prompt provider notification is a priority to trigger diagnostic workup and interventions. A temperature of 98.6°F is normal and not concerning for infection or rejection. Moderate serosanguinous drainage and mild nausea after oral analgesics are common postoperative/medication effects and are typically managed with routine nursing measures unless worsening or accompanied by other red flags.

Question 44

The nurse is observing a staff member caring for a 15-year-old client who is 12 hours postoperative craniotomy for brain tumor resection. Which of the following actions by the staff member would require the nurse to intervene?

Accepted Answer

Answer reason: Trendelenburg positioning increases venous return and impedes jugular venous drainage from the brain, which can raise ICP and worsen postoperative cerebral edema or bleeding risk. Repositioning should be done with the head and neck kept midline and the head of bed typically elevated as prescribed to promote venous outflow. Limiting visitors and supporting the head during repositioning reduce stimulation and prevent strain that could increase ICP, so those actions are appropriate.

Question 45

In what position should the nurse place a client recovering from general anaesthesia?

Accepted Answer

Answer reason: A side-lying (lateral recovery) position promotes drainage of oral secretions or vomitus and helps maintain a patent airway. High-Fowler may be used later to improve lung expansion, but it is less protective if the patient is not fully awake and cannot handle secretions. Supine and Trendelenburg both increase the risk of airway obstruction and aspiration in a sedated post-op patient.

Question 46

A nurse is caring for a client with closed angle glaucoma. Which of the following features should be reported to the healthcare provider (HCP)?

Accepted Answer

Answer reason: Seeing halos around lights is a classic symptom of acute angle closure due to corneal edema from markedly increased intraocular pressure and should prompt urgent provider notification. This finding helps distinguish a dangerous pressure crisis from less specific, non-urgent visual complaints. Prompt reporting supports immediate interventions (e.g., pressure-lowering therapy) to prevent permanent vision loss.

Question 47

A 5-year-old child has undergone a tonsillectomy. The nurse notices the child frequently swallowing while lying in bed. What is the nurse’s priority action?

Accepted Answer

Answer reason: Frequent swallowing after a tonsillectomy is a classic early sign of postoperative hemorrhage because the child may be swallowing blood trickling down the throat. Post-tonsillectomy bleeding can rapidly compromise airway and circulation, so rapid escalation is the priority nursing response. Interventions like pain medication or oral fluids can worsen bleeding risk or delay recognition of deterioration. Repositioning may improve drainage/airway protection but does not address the potentially life-threatening complication that requires urgent provider evaluation and possible operative management.

Question 48

Which among the following is the most important post-operative parameter to be observed in a child, immediately after tonsillectomy?

Accepted Answer

Answer reason: Frequent swallowing is a classic early sign of oozing/bleeding as the child repeatedly swallows blood draining into the throat, often before obvious vomiting occurs. Coffee-ground emesis may appear later after blood has been swallowed and partially digested, so it is less sensitive for early detection. Sore throat and a mild temperature rise are expected postoperative findings and are not as urgent as identifying bleeding promptly.

Question 49

A nurse is providing home instructions to a client with peripheral vascular disease. Which information should be included in the instructions?

Accepted Answer

Answer reason: Peripheral vascular disease reduces arterial perfusion, so patient teaching should focus on preventing additional impedance to blood flow and reducing ischemic injury risk. Crossing the legs can compress vessels at the groin or popliteal area and further decrease distal circulation, worsening pain and delaying tissue healing. Heat sources such as heating pads are unsafe because impaired sensation and poor perfusion increase burn risk. Walking barefoot and self-treating foot sores increase the chance of unnoticed trauma and infection, which can rapidly progress in poorly perfused tissue.

Question 50

A nurse is caring for a patient who returned to the unit after a cardiac catheterization. What should the nurse monitor for the initial 12 hours after the procedure? Select one?

Accepted Answer

Answer reason: A falling blood pressure (often with tachycardia, cool/clammy skin, or increasing groin pain/back pain) is a key early warning sign and requires immediate assessment of the access site, distal perfusion, and hemodynamic stability. While chest pain can indicate ischemia, the most expected immediate complication to monitor closely in the first hours is hemodynamic compromise from bleeding. Thrombus formation is a potential complication but is typically identified via limb ischemia signs and is less common as the primary immediate 12-hour monitoring focus than bleeding-related instability.

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The nurse is planning care for a client who underwent a craniotomy for removal of a brain tumor 8 hours ago. Which of the following would be a priority for the nurse to include in the plan of care?

The nurse is providing home care instructions to the parents of a 10-year-old child with hemophilia. Which sport activity should the nurse suggest for this child?

The nurse is caring for a client taking tamoxifen for breast cancer. Which client statement is most concerning and a priority to report to the health care provider?

Which of the following complications of an abdominal aortic repair is indicated by detection of a hematoma in the perineal area?

The nurse provides care for a patient who has just returned from an endovascular repair of an abdominal aortic aneurysm (AAA). Which assessment should the nurse perform first?

The nurse provides care for a patient who is postoperative for a thyroidectomy. Which clinical data indicates a need for immediate action by the nurse?

The nurse is caring for a client with Guillain-Barré syndrome (GBS). The nurse plans on taking which priority action?

The nurse is caring for a client who is receiving multiple chemotherapeutic medications to treat breast cancer. Which of the following statements by the client would require immediate follow-up?

The nurse is providing postoperative teaching for a client who underwent phacoemulsification of a cataract in the left eye. Which of the following information should the nurse include?

The nurse in the pediatric clinic instructs the parent of a preschool client diagnosed with asthma about preventative care. Which statement by the parent indicates to the nurse that further teaching is necessary?

A client with a testicular malignancy undergoes a radical orchiectomy. In the immediate postoperative period the nurse should particularly assess the client for?

The goal of nursing care for a client with acute myeloid leukemia (AML) is to prevent?

During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client’s?

The nurse has instructed the client about the correct positioning of his leg and hip following hip replacement surgery. Which of the following statements indicate that the client has understood these instructions?

A nurse is caring for a client who is diagnosed with tuberculosis. To achieve the desired outcome, which is the best nursing action?

The nurse is preparing a client for discharge the day after a kidney stone lithotripsy. Which statement made by the client would require further education?

The nurse should notify the physician immediately of which of the assessment findings?

A client is to be discharged 12 hours after delivery. The nurse should delay the discharge and notify the physician if which of the following is observed?

The nurse is caring for a client who is one-day post-operative following a total laryngectomy with a tracheostomy placement. When providing tracheostomy care, which assessment finding requires immediate follow-up?

The nurse is caring for a client with heart failure who has a magnesium level of 1.4 mg/dL. The nurse should?

The nurse reviews telephone messages in the pediatric clinic. Which message will the nurse return first?

The nurse is caring for four newborns during their shift in the unit. After performing an assessment, which newborn should the nurse see first?

The nurse is caring for a client who is six hours post-operative from a laparoscopic appendectomy. Which of the following findings requires immediate follow-up?

The nurse in a hematology clinic is evaluating clients’ risk for pernicious anemia. At highest risk for pernicious anemia is the?

The nurse is caring for a client following a bedside thoracentesis. Which action should the nurse take immediately following the procedure?

The telehealth nurse is teaching a client who was exposed to poison ivy. Which of the following information should the nurse include?

The nurse is planning care for a client receiving continuous renal replacement therapy (CRRT). Which of the following actions should the nurse include in the client's plan of care?

The nurse enters a client's room for the first time during the shift and realizes that the IV fluids are infusing 100 mL/hr faster than the prescribed rate. Which of the following actions should the nurse take first?

The nurse is monitoring a client following a lung resection. The hourly output from the chest tube was 300mL. The nurse should give priority to?

At PHC level, a women who complains of spotting following IUCD insertion should be advised?

Following a liver biopsy, the highest priority assessment of the patient's condition is to check for?

The nurse should teach a client that a normal local tissue response to radiation is?

The nurse is aware that a neonate of a mother with diabetes is at risk for what complication?

A nurse is caring for a client who had an insertion of radium for cancer of the cervix. For what radium reaction should the nurse assess the client?

A nurse is caring for a client who had an insertion of radium for cancer of the cervix. For what radium reaction should the nurse assess the client?

A nurse is caring for a client who is 24 hours postoperative cholecystectomy. Upon assessment, the nurse notes that the T-tube has drained 800 mL of green-brown drainage. Which would be the best action done by the nurse?

The nurse is screening clients for those at increased risk for developing neutropenia. At highest risk for developing neutropenia is the client who?

The nurse is planning care for a 6-year old client with acute glomerulonephritis. Which of the following interventions should the nurse include in the client's plan of care?

A 37-year-old client is scheduled for an induction at 38 weeks gestation for gestational diabetes. An IV is placed and the client is started on Pitocin. Which parameters are priority for the nurse to monitor while the client is having oxytocin infused?

The nurse is caring for a client with peritoneal dialysis. The client reports an outflow of only one-half of the dialysate solution that was dwelled. The nurse should instruct the client to do which of the following?

The nurse cares for a client who had a liver transplant 48 hours ago. It would be a priority for the nurse to notify the healthcare provider (HCP) if the client has?

The nurse is observing a staff member caring for a 15-year-old client who is 12 hours postoperative craniotomy for brain tumor resection. Which of the following actions by the staff member would require the nurse to intervene?

In what position should the nurse place a client recovering from general anaesthesia?

A nurse is caring for a client with closed angle glaucoma. Which of the following features should be reported to the healthcare provider (HCP)?

A 5-year-old child has undergone a tonsillectomy. The nurse notices the child frequently swallowing while lying in bed. What is the nurse’s priority action?

Which among the following is the most important post-operative parameter to be observed in a child, immediately after tonsillectomy?

A nurse is providing home instructions to a client with peripheral vascular disease. Which information should be included in the instructions?

A nurse is caring for a patient who returned to the unit after a cardiac catheterization. What should the nurse monitor for the initial 12 hours after the procedure? Select one?

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