Question 1

The nurse is caring for a child with a new full-leg cast. Which of the following is an appropriate nursing intervention for this client?

Accepted Answer

Answer reason: Smoothing or padding rough edges reduces friction and protects vulnerable skin, especially around the heel, ankle, and popliteal area in a full-leg cast. The other options reflect unsafe casting care: a newly applied casted limb should be repositioned to promote drying and prevent pressure injury, and the extremity is typically elevated early to decrease swelling and neurovascular compromise. Additionally, casts should be handled with the palms rather than fingertips to avoid indentations that can create pressure areas.

Question 2

A home health nurse is caring for a patient on Warfarin. The patient has a large hematoma on his forehead and reports he fell yesterday. What action should the nurse implement?

Accepted Answer

Answer reason: A large forehead hematoma after a fall is a red flag that warrants prompt medical evaluation (often imaging and INR assessment) rather than home-only comfort measures. Holding anticoagulation is not within typical nursing scope as an independent home-health action without provider direction and could increase thromboembolic risk if done inappropriately. Interventions like ice and fall-prevention are appropriate but are secondary to addressing the immediate risk of serious bleeding complications.

Question 3

A 48-year-old male has been admitted to the medical unit for pancreatitis and a gastrointestinal bleed. He states he smokes a half-pack of cigarettes per day and has a history of alcohol abuse. His current vitals are BP 145/92, pulse 98 bpm, and temperature 99.1 degrees Fahrenheit. Which is the most important for the nurse to implement?

Accepted Answer

Answer reason: Establishing the last drink time and amount is the key immediate assessment that drives risk stratification and triggers appropriate monitoring (e.g., CIWA), seizure precautions, and early treatment planning. The current vital signs do not show shock requiring immediate transfusion action, and there is no evidence provided of active massive bleeding. An incentive spirometer is beneficial but is not as urgent as preventing/anticipating acute withdrawal complications. Requesting benzodiazepines may be appropriate later, but it should follow assessment and protocol-based evaluation rather than being the first implementation step.

Question 4

The nurse is educating a patient diagnosed with unstable angina. Which statement by the patient would indicate the need for further teaching?

Accepted Answer

Answer reason: Unstable angina reflects myocardial ischemia with an increased short-term risk of myocardial infarction and requires urgent evaluation, not reassurance based on symptom frequency. This statement shows a dangerous misunderstanding that ongoing or intermittent chest pain can still precede an MI even if episodes are not increasing. Appropriate teaching emphasizes risk-factor modification and promptly reporting any change/worsening or unrelieved symptoms, because progression can be sudden. Options about stopping smoking, notifying the provider about changing symptoms, and diet/exercise are consistent with reducing ischemia triggers and overall cardiovascular risk.

Question 5

The nurse prepares to insert a nasogastric (NG) tube into a client who sustained severe facial injury due to a motor vehicle accident. Which finding requires the nurse to notify the health care provider (HCP) prior to performing the prescribed procedure?

Accepted Answer

Answer reason: A halo sign suggests cerebrospinal fluid leakage from a basilar skull fracture, making blind nasal instrumentation unsafe. In this setting, an NG tube can be inadvertently advanced intracranially through a disrupted cribriform plate, causing catastrophic injury and infection risk. The appropriate nursing action is to stop and urgently notify the HCP so an alternative route (e.g., orogastric tube) and further evaluation can be used. Local facial bleeding, headache, and forehead bruising can occur with trauma but do not specifically indicate a contraindication to NG insertion the way suspected CSF rhinorrhea does.

Question 6

The experienced pediatric intensive care registered nurse is precepting a newly licensed registered nurse who received report on 4 clients. Which of the following actions taken by the new nurse requires the experienced nurse to intervene?

Accepted Answer

Answer reason: Oropharyngeal suctioning is a stimulating procedure that can trigger laryngospasm, increased edema, and acute respiratory distress in a child with upper-airway compromise. Drooling signals potential severe upper-airway involvement, so the priority is to keep the child calm, provide humidified oxygen as needed, and prepare for escalation (eg, nebulized epinephrine, corticosteroids) rather than performing provocative procedures. By contrast, the other actions reflect appropriate isolation/positioning/medication safety principles in common pediatric scenarios.

Question 7

A client recently diagnosed with heart failure is being discharged on the angiotensin-converting enzyme inhibitor lisinopril. Which information related to this new medication is important for the nurse to reinforce at discharge?

Accepted Answer

Answer reason: Teaching slow position changes and dangling at the bedside reduces orthostatic symptoms and helps prevent injury after discharge. Monitoring “drug levels” is not a standard requirement for lisinopril; instead, renal function and potassium may be followed. Encouraging high-potassium foods is unsafe because ACE inhibitors can increase potassium, and holding the medication based on heart rate is a teaching point more characteristic of beta-blockers or certain calcium channel blockers than ACE inhibitors.

Question 8

A nurse is caring for a client on bed rest. How can the nurse help prevent a pulmonary embolus?

Accepted Answer

Answer reason: Regular leg exercises (e.g., ankle pumps, quad/gluteal sets) promote venous return and reduce clot formation that could embolize to the lungs. Positioning the knee gatch can actually impede venous return by compressing vessels behind the knee and is not a VTE-prevention strategy. Incentive spirometry prevents atelectasis/pneumonia rather than embolic events, and restricting fluids can worsen hemoconcentration and increase thrombosis risk.

Question 9

The nurse is reviewing the history of four new clients admitted to the med-surg unit. All four of these clients have low serum hemoglobin. Which client is at highest risk for anemia due to gastrointestinal bleeding?

Accepted Answer

Answer reason: Advanced age further increases susceptibility to NSAID-related mucosal injury and bleeding complications. CKD on dialysis more commonly causes anemia from decreased erythropoietin and reduced RBC survival rather than primary GI blood loss. Short-term ibuprofen use for only a few days is less likely to produce clinically significant bleeding compared with long-term NSAID exposure in an older adult.

Question 10

The nurse is caring for a 68-year-old individual in the emergency department who had been on the bathroom floor for about 10 hours after a fall. While performing straight catheterization, the nurse notes that the urine output reaches 800 mL and continues to flow heavily. What action should the nurse take, and what is the rationale for this action?

Accepted Answer

Answer reason: Prolonged immobilization after a fall raises concern for rhabdomyolysis and acute kidney injury, so close monitoring of urine output is a key complication-prevention priority. Ongoing heavy flow after an initial large return suggests significant urinary retention with continued decompression and/or post-obstructive diuresis, both of which require accurate, ongoing measurement of output. An indwelling catheter provides continuous drainage and precise hourly I&O data needed to guide fluids and detect deterioration early. Stopping drainage solely to prevent UTI or spasms is not appropriate in the face of a potentially evolving renal emergency, and obtaining a sample does not address the immediate need for ongoing monitoring.

Question 11

A nurse is caring for a client who had a total hip replacement 2 days ago. The client needs to get out of bed to the chair. What is the most important instruction the nurse should give the client?

Accepted Answer

Answer reason: Maintaining hip precautions after total hip arthroplasty is essential to prevent prosthetic hip dislocation in the early postoperative period. Limiting hip flexion to no more than 90 degrees during transfers to a chair directly reduces posterior dislocation risk, especially when combined with avoiding internal rotation and adduction. Bending forward at the waist to sit increases hip flexion beyond the safe range and is unsafe. Keeping the legs together can promote adduction across midline, another movement that increases dislocation risk, and weight-bearing should follow the specific provider/PT order rather than shifting most weight onto the operative leg.

Question 12

A patient is prescribed a wound vac for a deep sacral wound. Which finding requires immediate intervention?

Accepted Answer

Answer reason: A “low pressure” alarm typically indicates an air leak, tubing disconnection/kink, or a canister/seal problem, meaning therapeutic suction is not being delivered and the system is failing. This requires prompt troubleshooting (check seal edges, tubing connections, canister, and settings) to restore ordered pressure and prevent delayed healing or infection risk. By contrast, an inward-collapsed dressing generally indicates suction is functioning, and mild discomfort or scant serous output can be expected depending on wound characteristics and therapy settings.

Question 13

A nurse is caring for a post-op patient with a temperature of 95°F (35°C), shivering, and cold skin. What is the priority intervention?

Accepted Answer

Answer reason: Active external rewarming is the priority because it addresses the underlying problem quickly and effectively in a symptomatic patient at 35°C. Warm oral fluids may help but are slower/limited and may be inappropriate depending on postoperative diet/NPO status. Reassessing without intervention delays treatment, and PRN analgesia does not correct the thermoregulatory instability driving the patient’s symptoms.

Question 14

A client with schizoaffective disorder has been stable on clozapine for 8 months. During today's assessment, the nurse notes that the client appears mildly fatigued, reports new-onset sore throat, and states that voices have been whispering again but not commanding. Vital signs: HR 102, BP 118/74, Temp 37.6°C (99.7°F). Which nursing action is the priority?

Accepted Answer

Answer reason: B. Notify the provider immediately and obtain a stat CBC with differential Clozapine can cause potentially life-threatening agranulocytosis/neutropenia, and early symptoms may include sore throat, fatigue, and low-grade fever, making possible infection the immediate safety threat. The priority is to urgently evaluate the absolute neutrophil count via CBC with differential and notify the provider so clozapine can be held and further management initiated if neutropenia is present. The return of non-command auditory hallucinations is clinically important but is not as immediately life-threatening as suspected clozapine-induced neutropenia. Giving PRN anxiolytics or focusing on stressors could delay recognition and treatment of a serious hematologic complication.

Question 15

The nurse is performing discharge teaching to the parents of a 17-year-old male diagnosed with a moderate concussion. Which of the following statements by the parents would indicate effective understanding?

Accepted Answer

Answer reason: " After a concussion, patients can have slowed reaction time, impaired attention, dizziness, and delayed processing, which significantly increases risk for motor vehicle crashes and reinjury. Restricting driving until reassessment supports safety and monitoring for evolving symptoms or complications. A common misconception is that the patient should resume sports quickly; returning to play the next day is unsafe because second-impact injury can be catastrophic. Routine waking every two hours is not generally required unless specifically instructed based on severity and current neurologic risk, and activity/sleep should be balanced with cognitive and physical rest rather than forced wakefulness.

Question 16

The nurse is aware that a child is at increased risk for an asthma-related death when there has been?

Accepted Answer

Answer reason: A prior ICU admission for asthma indicates a history of severe, life-threatening exacerbations and is one of the strongest predictors of future asthma-related mortality. It reflects poor disease control and high risk for rapid deterioration. The other options represent less severe disease or common management situations and do not carry the same level of mortality risk.

Question 17

A patient with left-sided heart failure is short of breath and has crackles. Which order should the nurse question?

Accepted Answer

Answer reason: Left-sided heart failure with crackles indicates pulmonary congestion from volume overload and elevated left-sided filling pressures. Administering an isotonic fluid infusion at a relatively high maintenance rate risks worsening intravascular volume, increasing pulmonary edema, and further compromising gas exchange. In contrast, IV loop diuretics reduce preload and pulmonary congestion, supplemental oxygen supports oxygenation, and an ACE inhibitor can be appropriate for afterload reduction if hemodynamics allow. Therefore the continuous normal saline infusion is the order most likely to precipitate deterioration and should be clarified.

Question 18

A patient with acute lymphoblastic leukemia began chemotherapy 24 hours ago. The patient is experiencing nausea, muscle weakness, and an irregular heart rate. What is the nurse's priority?

Accepted Answer

Answer reason: The combination of muscle weakness and an irregular heart rate is most concerning for an electrolyte-driven dysrhythmia risk that requires prompt lab surveillance and rapid intervention. Monitoring calcium (along with other tumor lysis electrolytes) targets a life-threatening complication rather than symptom control. Antiemetics address comfort but do not mitigate the immediate arrhythmia risk, and infection/platelets are important in leukemia but are less directly linked to these acute post-chemo findings.

Question 19

The nurse reviews a woman’s medical history prior to performing a pelvic examination. Which of the following findings is most important to report to the patient’s provider?

Accepted Answer

Answer reason: Reporting this promptly supports risk reduction by ensuring appropriate assessment (vital signs, pregnancy test if indicated, hemoglobin) and planning for additional diagnostics or urgent management. A history of HPV is clinically relevant for cervical cancer screening, but it does not typically require urgent escalation before a routine pelvic exam in the absence of concerning symptoms. Past cesarean birth and remote mastectomy history are important background data but are less likely to represent an immediate complication requiring prompt provider notification for today’s exam.

Question 20

A patient with a cast, for a left tibial fracture, receives morphine for pain. Approximately 30 minutes later, the patient reports increasing pain like 'pins and needles' at his left foot despite the morphine injection. What should be the nurse's next action?

Accepted Answer

Answer reason: The immediate nursing priority is a focused neurovascular assessment (circulation, sensation, movement), and checking distal pulses is a key first step to determine adequacy of perfusion beyond the cast. Poor or diminished pulses (along with worsening pain out of proportion, pallor, coolness, delayed cap refill, or increasing numbness) requires urgent escalation and likely cast loosening/bivalving per provider orders. Re-rating pain or checking blood pressure does not address the limb-threatening complication, and allergy assessment is not consistent with localized pins-and-needles symptoms after an appropriate opioid dose.

Question 21

Which of the following findings should the nurse report to the provider when assessing a patient's stoma?

Accepted Answer

Answer reason: Pallor suggests decreased blood flow/ischemia, which is a time-sensitive postoperative complication requiring prompt provider notification. In contrast, liquid output is expected with an ileostomy, and moisture is normal for mucosal tissue. Red coloration is also an expected normal finding when perfusion is adequate.

Question 22

A patient reports sweet-tasting drainage from their nose, a headache, and the nurse notes a halo-sign of the drainage. Which of the following is likely present?

Accepted Answer

Answer reason: This finding signals a high-risk complication because it creates a direct pathway for pathogens, increasing meningitis risk and requiring prompt protection of the airway and avoidance of nasal instrumentation. A simple nosebleed more often produces uniform blood without the classic serous separation pattern. CVA and sinus infection do not typically produce the halo sign or sweet-tasting clear rhinorrhea.

Question 23

The nurse is caring for a client receiving enteral nutrition via a nasogastric tube. The client has a residual of 250 mL. Which of the following actions should the nurse take?

Accepted Answer

Answer reason: Holding the feeding is the safest immediate nursing action while reassessing the client (bowel sounds, abdominal distention, nausea/vomiting) and ensuring appropriate head-of-bed elevation. Flushing with a large volume is inappropriate and can worsen gastric volume and aspiration risk. Repositioning may help gastric emptying but does not address the immediate safety concern when residual is already high; the nurse should hold the feeding and then follow agency policy for recheck and provider notification if persistent.

Question 24

The nurse educator teaches a nurse about physical assessment for a client with an abdominal aortic dissection. Which statement by the nurse indicates understanding?

Accepted Answer

Answer reason: Aortic dissection creates a fragile, high-risk vascular injury where increased mechanical pressure can worsen the tear or precipitate rupture and hemorrhage. Abdominal palpation can increase discomfort, provoke sympathetic stimulation (raising blood pressure), and in some cases disrupt an unstable vascular lesion. Assessment should emphasize observation, vital signs, perfusion checks, and gentle auscultation rather than deep or repeated palpation. Options focused on positioning or carotid bruits do not address the primary assessment safety risk for an abdominal aortic dissection.

Question 25

A mother calls a hospital hotline stating that she found her child with an unknown substance around the mouth and an unmarked bottle nearby. Which question should the nurse ask first to determine if the child has ingested a corrosive substance?

Accepted Answer

Answer reason: Corrosive ingestion causes immediate tissue damage, leading to burning in the mouth and throat. Identifying these early symptoms helps recognize a high-risk situation and prevent serious complications such as airway injury or esophageal damage.

Question 26

The nurse is caring for a male patient with end-stage kidney disease (ESKD) who is on hemodialysis and has an Arteriovenous (AV) fistula in the left forearm. Which of the following patient assessment data should the addressed first?

Accepted Answer

Answer reason: New tingling/numbness in the fingers is an early sign of ischemia and should trigger immediate checks of pulses, capillary refill, temperature, color, pain, and comparison with the other extremity, along with notifying the provider/dialysis team. Hearing a bruit over the fistula is an expected finding that suggests patency rather than an urgent complication. In ESKD on hemodialysis, low or absent urine output may be baseline, and abdominal pain/diarrhea is concerning but is less immediately limb-threatening than possible acute distal ischemia.

Question 27

The nurse judges that the mother understands the diet restrictions for her child with chronic renal failure who is receiving peritoneal dialysis when she reports providing a diet involving which of the following?

Accepted Answer

Answer reason: Chronic renal failure reduces the kidneys’ ability to excrete phosphorus and nitrogenous waste, so diet therapy focuses on lowering phosphate burden and limiting uremic toxin production. Restricting dietary phosphorus helps prevent renal osteodystrophy/secondary hyperparathyroidism and reduces complications related to hyperphosphatemia. Protein intake is commonly controlled to decrease urea generation and symptom burden, while dialysis handles removal of some wastes but does not eliminate the need for dietary management. By contrast, a “high potassium” diet is unsafe because impaired renal clearance predisposes to hyperkalemia and life-threatening dysrhythmias.

Question 28

A 45-year-old client is admitted to the medical telemetry unit to observe for possible dysrhythmias. After waking in the morning, the client asks the nurse for coffee. Which of the following would be the best response by the nurse?

Accepted Answer

Answer reason: Caffeine is a cardiac stimulant that can increase sympathetic activity and precipitate or worsen dysrhythmias, especially in a client on telemetry for rhythm observation. The safest nursing response is to provide a clear, patient-centered rationale tied to the current clinical risk and monitoring purpose. This supports prevention of complications by avoiding potentially arrhythmogenic triggers. Other choices are non-therapeutic (vague prohibition), rely on authority rather than teaching, or offer an alternative that may still contain caffeine and does not address the clinical concern.

Question 29

Which of the following is a priority consideration when applying a new tracheostomy tie?

Accepted Answer

Answer reason: The priority is preventing accidental decannulation and airway loss during a tracheostomy tie change. Keeping the existing ties in place until the new ties are fully secured maintains tube stability while the stoma is vulnerable, especially in newer tracheostomies. While ensuring appropriate tightness (e.g., finger breadths) helps prevent skin injury and venous obstruction, it does not address the immediate highest-risk complication during the change. A double knot may reduce loosening but is secondary to maintaining continuous securement of the airway device throughout the procedure.

Question 30

A patient diagnosed with appendicitis has been experiencing 8/10 pain, but tells the nurse “I actually feel a lot better all of a sudden.” What is the nurse’s priority action?

Accepted Answer

Answer reason: The priority is rapid escalation to the provider/surgical team because the patient may need urgent intervention, antibiotics, and close monitoring for peritonitis and sepsis. Checking labs or taking a temperature are secondary assessments and should not delay escalation when a high-risk complication is suspected. Changing analgesics does not address the life-threatening complication and could also mask worsening assessment findings.

Question 31

A client with type 1 diabetes contacts the home care nurse to report nausea and abdominal pain. The nurse should advise the client to do what?

Accepted Answer

Answer reason: More frequent glucose checks guide timely decisions about hydration, carbohydrate intake, and whether urgent evaluation is needed. Holding insulin is unsafe in type 1 diabetes because illness commonly increases counterregulatory hormones and insulin needs, raising risk for diabetic ketoacidosis. Increasing simple sugars is only indicated for hypoglycemia, and increasing activity can worsen hyperglycemia/ketosis and dehydration during illness.

Question 32

A visiting nurse finds that a homebound client has not been cleaned for several days, despite having a home health aide assigned. What is the nurse's first action?

Accepted Answer

Answer reason: The priority is to assess the client for signs of harm such as skin breakdown, infection, or neglect-related complications. Nursing practice requires assessment before intervention, ensuring that immediate risks are identified and addressed before reporting or documentation.

Question 33

The nurse is taking the health history of a 70-year-old patient being treated for a Duodenal Ulcer. After being told the patient is complaining of epigastric pain, the nurse expects to note which assessment finding?

Accepted Answer

Answer reason: Epigastric pain in an older adult with a known duodenal ulcer should prompt assessment for occult or overt bleeding as a key complication. This finding is more specific and clinically consequential than nonspecific symptoms such as nausea. Hernia and hyperthermia are not typical expected findings directly linked to uncomplicated duodenal ulcer pain and would suggest alternative diagnoses or complications.

Question 34

Which of the following measures should the nurse focus on for the client with esophageal varices?

Accepted Answer

Answer reason: Nursing priority is early detection of bleeding and rapid escalation to prevent hypovolemic shock, airway compromise, and death. Key cues include hematemesis, melena, tachycardia, hypotension, pallor, decreasing hemoglobin/hematocrit, and altered mental status. While controlling blood pressure, nutrition, and teaching are supportive, they do not address the most immediate life-threatening complication.

Question 35

Which of the following factors should be the main focus of nursing management for a client hospitalized for cholecystitis?

Accepted Answer

Answer reason: Ongoing monitoring of pain pattern, abdominal guarding/rigidity, fever trends, vital signs, WBCs, and worsening jaundice helps detect deterioration before it becomes life-threatening. While antibiotics and possible surgery are important components of treatment, they are medical orders that are guided by the patient’s evolving status and do not replace vigilant surveillance. Lithotripsy is not a typical acute inpatient priority for cholecystitis management compared with monitoring for complications and instability.

Question 36

When evaluating a male client for complications of acute pancreatitis, the nurse would observe for?

Accepted Answer

Answer reason: A drop in urine output is an early, clinically important indicator of impaired renal perfusion and inadequate circulating volume, making it a key complication to monitor. Intracranial pressure findings are not a typical pancreatitis complication pattern, and bradycardia is less expected than tachycardia with hypovolemia. Hypertension also does not fit the usual hemodynamic trend of volume depletion and systemic inflammation, where hypotension is more concerning.

Question 37

Clients with chronic illnesses are more likely to get pneumonia when which of the following situations is present?

Accepted Answer

Answer reason: It also contributes to reduced respiratory muscle strength and less effective cough, increasing secretion retention and risk for lower respiratory tract infection. Among the options, this is the most direct, well-established host factor that increases susceptibility to pneumonia. Group living increases exposure risk, but the stem emphasizes chronic illness vulnerability where compromised host defenses are the key driver. Dehydration and periodontal disease can contribute to illness risk, but they are less consistently predictive than overall nutritional deficit for developing pneumonia.

Question 38

A client admitted with acute coronary syndrome complains of persistent chest pain despite receiving nitroglycerin. The nurse observes the following: BP 88/52, HR 104, RR 22, O2 sat 95%. Which prescription should the nurse question?

Accepted Answer

Answer reason: Beta-blockers can worsen hypotension by decreasing heart rate and contractility, reducing cardiac output and coronary perfusion in an already low-pressure state. With a BP of 88/52, giving metoprolol risks precipitating shock and masking compensatory tachycardia. In ACS, beta-blockers are used when hemodynamically stable; hypotension is a key reason to hold and clarify the order. By contrast, a small IV fluid bolus can support preload and blood pressure, and proceeding toward PCI addresses the underlying ischemia driving persistent pain.

Question 39

When caring for a client who is treated with artificial skin, which intervention is most significant to promote grafting success?

Accepted Answer

Answer reason: Limiting range-of-motion that stretches or moves the grafted area reduces mechanical disruption, prevents hematoma/seroma formation under the graft, and supports revascularization. Nutrition is important for healing, but increasing only carbohydrates is not the key determinant of graft take compared with immobilization/protection of the site. Fluid restriction is generally contraindicated in burn/wound patients because adequate perfusion and hydration support tissue oxygenation and healing.

Question 40

Mr. and Mrs. Smith’s child has hemophilia; which of the following actions would you instruct them to avoid?

Accepted Answer

Answer reason: Elevation of an injured extremity helps reduce hydrostatic pressure and bleeding; therefore, lowering the injured area would worsen bleeding and swelling and should be avoided. Immobilizing the joint and applying cold are appropriate to reduce movement-related bleeding and vasoconstrict local vessels. Applying direct pressure is also appropriate for external bleeding control, whereas dependent positioning promotes continued oozing.

Question 41

A nurse is caring for a 68-year-old female patient who had a stroke several days ago. The nurse finds the patient has developed right-sided facial drooping and weakness in the right arm and leg. The patient is increasingly confused and has a new onset of nausea, vomiting and a severe headache. Her blood pressure is 185/111 mmHg, and she is experiencing bradycardia with a heart rate of 48 beats per minute. What is the nurse’s best initial action?

Accepted Answer

Answer reason: The combination of acute neurologic worsening with severe headache, vomiting, confusion, hypertension, and bradycardia is concerning for increased intracranial pressure and possible hemorrhagic conversion or expanding intracranial bleed after stroke. The safest first priority is rapid reassessment (focused neuro assessment/NIHSS, pupils, LOC, vital trends) and immediate escalation to the provider/rapid response to trigger urgent imaging and ICP-focused management. Symptom-only treatment (e.g., analgesic) can delay recognition and definitive intervention and does not address the life-threatening cause. Head-of-bed elevation can be an appropriate supportive measure, but it is not as high-priority as recognizing deterioration and urgently activating the medical response for a potential intracranial emergency.

Question 42

Most common postoperative complication of abdominal surgery?

Accepted Answer

Answer reason: Surgical site infection is the most common postoperative complication following abdominal surgery due to tissue disruption, contamination risk, and impaired host defenses. It occurs more frequently than hemorrhage, anastomotic leak, or pulmonary embolism.

Question 43

Situation: Developing countries such as the Philippines suffer from high infant and child mortality rates. Thus, as a management to the existing problem, the WHO and UNICEF launched the IMCI. Using IMCI Chart, this child can be manage with?

Accepted Answer

Answer reason: Give the first dose of antibiotic, give Vit. A, apply Gentian Violet for mouth ulcers and refer urgently to hospital IMCI management prioritizes immediate stabilization and urgent referral when a child meets “danger sign”/severe classification criteria suggesting high risk of rapid deterioration. Pre-referral treatment includes giving the first dose of an appropriate antibiotic to begin coverage for serious bacterial infection, and vitamin A when indicated to reduce morbidity and mortality in susceptible children. Mouth ulcers in severe classifications are managed with topical therapy to reduce pain and improve oral intake while definitive care is arranged. Options that only provide symptomatic treatment or outpatient follow-up are inappropriate when the IMCI chart indicates urgent referral due to risk of complications.

Question 44

A 2-year-old child is receiving temporary total parenteral nutrition (TPN) through a central venous line. This is the first day of TPN therapy. Although all of the following nursing actions MUST be included in the plan of care of this child, which one would be a priority at this time?

Accepted Answer

Answer reason: Initiating TPN introduces a high dextrose load, and the earliest, most immediate complication is acute hyperglycemia (or rebound hypoglycemia if interrupted), which can rapidly become clinically significant in a toddler. Close glucose monitoring on day 1 guides prompt adjustment of infusion rate/insulin and helps prevent dehydration, osmotic diuresis, and electrolyte shifts. While strict aseptic technique and maintaining catheter integrity are essential, they are ongoing line-safety measures rather than the most time-sensitive metabolic risk at initiation. Liver function monitoring is important with prolonged TPN, but hepatobiliary complications are not the primary first-day priority.

Question 45

Next-Gen NCLEX (Standalone / Case-Based) Case Scenario for Questions 8–10: A client with non-Hodgkin's lymphoma is undergoing chemotherapy. Current labs: WBC: 1,800/mm³ Hgb: 8.9 g/dL Platelets: 45,000/mm³ Uric acid: 9 mg/dL (high) Which complication is the client MOST at risk for?

Accepted Answer

Answer reason: The elevated uric acid (9 mg/dL) strongly supports increased nucleic acid breakdown, which is a hallmark of this process and can precipitate acute kidney injury. This complication is more directly linked to the presented data than DVT, which is a cancer risk but is not suggested by the specific lab pattern provided. Hypokalemia is inconsistent because the expected electrolyte disturbance is hyperkalemia from cellular lysis, not low potassium.

Question 46

A client who has had a total hip replacement has a dislocated hip prosthesis. The nurse should first?

Accepted Answer

Answer reason: A dislocated hip prosthesis is an acute postoperative complication that typically requires urgent provider evaluation and reduction to prevent neurovascular compromise and further tissue damage. The nurse’s priority is rapid escalation so definitive management can occur and to prevent inappropriate manipulation that could worsen the dislocation. Nursing measures like ice may help pain/swelling but do not address the underlying emergency. Applying traction or repositioning without a specific prescription can exacerbate injury and delay timely reduction.

Question 47

For a male client in the oliguric phase of acute renal failure (ARF), which nursing intervention is most important?

Accepted Answer

Answer reason: In the oliguric phase of acute renal failure, the kidneys cannot excrete water effectively, so fluid overload is a high-priority, life-threatening complication (pulmonary edema, hypertension, heart failure). Restricting fluids helps prevent worsening edema and respiratory compromise while closely matching intake to output plus insensible losses. Carbohydrates may be used to meet caloric needs and reduce protein catabolism, but this is secondary to preventing volume overload. Coughing/deep breathing and pain relief are supportive measures and do not address the most immediate physiologic risk in oliguria.

Question 48

A female client with chronic renal failure (CRF) is receiving a hemodialysis treatment. After hemodialysis, nurse Sarah knows that the client is most likely to experience?

Accepted Answer

Answer reason: Hemodialysis removes excess fluid and solutes from the intravascular space via ultrafiltration, so an immediate post-treatment effect is a lower body weight. This is why pre- and post-dialysis weights are used to estimate fluid removed and guide dry-weight goals. Increased blood pressure is less likely immediately after dialysis because volume removal more commonly predisposes to hypotension. Increased urine output is not expected in chronic renal failure because residual renal function is typically limited, and dialysis does not restore kidney filtration.

Question 49

A client is scheduled for a cardiac catheterization using a radiopaque dye. Which of the following assessments is most critical before the procedure?

Accepted Answer

Answer reason: This assessment directly affects whether the procedure can proceed as planned and what emergency precautions are required. Baseline peripheral pulses are important but are primarily used to compare postprocedure circulation after arterial access, not to prevent an acute preprocedure life-threatening event. Intake/output and height/weight are useful for renal-risk mitigation and dosing considerations, but they are less critical than allergy history for immediate procedural safety.

Question 50

An enema is prescribed for a client with suspected appendicitis. Which of the following actions should the nurse take?

Accepted Answer

Answer reason: Enemas are contraindicated in suspected appendicitis because they may increase the risk of perforation. The nurse must recognize this potential complication and question the order before proceeding.

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