Question 1

A clinic nurse is assessing a 15-year-old who was playing in a basketball tournament outside all day. The current weather is 93 degrees with high humidity. The patient states he is tired but feels “pretty normal.” He states the only reason he came in because “my pee was real dark like soda and it freaked me out.” The nurse knows this can be serious and should?

Accepted Answer

Answer reason: The safest priority is to assess for complications by checking renal function (BUN/creatinine) and muscle breakdown markers (myoglobin), guiding urgency and treatment intensity (e.g., aggressive IV fluids, monitoring electrolytes). Encouraging oral fluids and providing hydration education are appropriate but can delay recognition of a potentially life-threatening complication. Asking about intake/output is useful assessment, but it does not directly evaluate the suspected pathophysiology or quantify kidney injury risk.

Question 2

Which of the following statements by a diabetic patient is most concerning?

Accepted Answer

Answer reason:  Sick-day rules for diabetes emphasize that illness increases counterregulatory hormones and can raise glucose and ketone production even with reduced oral intake. Stopping insulin places the patient at high risk for severe hyperglycemia, ketosis, and diabetic ketoacidosis, which is an acute, potentially life-threatening complication. A safer approach is to continue prescribed basal insulin, monitor glucose/ketones more frequently, hydrate, and seek guidance for dose adjustments. The other statements reflect appropriate self-care or appropriate escalation for concerning symptoms rather than a dangerous misconception.

Question 3

Twenty-four hours after TURP surgery, the client tells the nurse he has lower abdominal discomfort. The nurse notes that the catheter drainage has stopped. The nurse’s initial action should be to?

Accepted Answer

Answer reason: The least invasive first step is to check patency by ensuring there are no dependent loops and gently milking the tubing to dislodge small clots. If drainage does not resume or obstruction is suspected to persist, then catheter irrigation per protocol/order is typically the next step. Removing the catheter is unsafe post-TURP due to bleeding and urinary retention risk, and notifying the provider comes after immediate bedside troubleshooting when the patient is symptomatic.

Question 4

A gravida 3 para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy. Which observation would the nurse be expected to make after the amniotomy?

Accepted Answer

Answer reason: This finding indicates intact fetal oxygenation without meconium staining and is the expected, non-complicated post-amniotomy observation. Greenish fluid suggests meconium, which raises concern for fetal stress and requires closer fetal monitoring and possible intervention. A visible umbilical cord segment would suggest cord prolapse, an obstetric emergency rather than an expected outcome.

Question 5

Which of the following nursing interventions should be implemented to manage a client with appendicitis?

Accepted Answer

Answer reason: Monitoring for peritonitis (e.g., increasing generalized abdominal pain, rigidity/guarding, rebound tenderness, fever, tachycardia) supports rapid escalation for urgent surgical management. Encouraging oral fluids is inappropriate because clients are typically kept NPO in anticipation of surgery and to reduce aspiration risk with anesthesia. Pain assessment is important but is less critical than identifying a life-threatening complication that changes management immediately.

Question 6

The nurse is providing discharge teaching for the client with leukemia. The client should be told to avoid?

Accepted Answer

Answer reason: Flossing can abrade gingival tissue and precipitate prolonged bleeding, so it is avoided or deferred until platelet counts are adequate and the provider approves. By contrast, an electric razor is recommended to reduce skin nicks and bleeding. Oil- or cream-based soaps are typically helpful for dry, fragile skin and are not a bleeding-risk activity.

Question 7

A 28-year-old male has been found wandering around in a confusing pattern. The male is sweaty and pale. Which of the following tests is most likely to be performed first?

Accepted Answer

Answer reason: Point-of-care capillary glucose is fast, noninvasive, and guides urgent treatment (e.g., oral glucose or IV dextrose) before pursuing slower diagnostics. A CT scan may be indicated for neurologic causes, but it should not delay ruling out and treating hypoglycemia. Blood cultures and ABGs are more situational and are not the first-line screening test for this presentation when hypoglycemia is suspected.

Question 8

The nurse is caring for a client after a lumbar puncture (spinal tap). Which client assessment is most concerning and requires a nursing response?

Accepted Answer

Answer reason: Clear drainage at the puncture site after a lumbar puncture suggests ongoing cerebrospinal fluid leakage, which raises concern for persistent dural leak and increased risk for complications such as meningitis and intracranial hypotension. This finding requires immediate nursing action: reinforce/maintain sterile dressing, keep the client flat per protocol, assess neurologic status/vitals, and promptly notify the provider. A post–dural puncture headache can be common and expected, whereas visible continuous leakage from the site is a more urgent abnormal assessment. Intake of 600 mL over 4 hours and lying on the side can be consistent with routine post-procedure care unless other abnormal signs are present.

Question 9

A client in labor is transported to the delivery room and prepared for a cesarean delivery. After the client is transferred to the delivery room table, the nurse should place the client in which position?

Accepted Answer

Answer reason: Left uterine displacement (achieved by placing a wedge under the right hip) shifts the uterus off the inferior vena cava and aorta, improving maternal hemodynamics and fetal oxygenation before/during cesarean preparation. This positioning is a standard safety intervention to prevent intraoperative hypotension and fetal compromise. Trendelenburg with stirrups and prone positioning are inappropriate and unsafe for a term laboring patient. Semi-Fowler’s without uterine displacement does not reliably prevent aortocaval compression on the operating table.

Question 10

The RN is preparing to have a patient who has acute leukemia sign the permit for a bone marrow aspiration. The patient states that the oncologist has explained the procedure and the complications, and she has no further questions. What assessment is most important for the RN to complete before the procedure is carried out?

Accepted Answer

Answer reason: Bone marrow aspiration is an invasive procedure with a key immediate risk of bleeding, and patients with acute leukemia often have thrombocytopenia from marrow failure. Checking the platelet count best predicts procedure-related hemorrhage risk and guides whether platelet transfusion or delay is needed to prevent a complication. Leukocyte count relates more to infection risk but is less directly linked to the most acute procedural hazard. NPO status is generally not required for aspiration done with local anesthesia (with or without minimal sedation), so it is not the most important pre-procedure assessment here.

Question 11

Nurse Ruth is assessing a client after a thyroidectomy. The assessment reveals muscle twitching and tingling, along with numbness in the fingers, toes, and mouth area. The nurse should suspect which complication?

Accepted Answer

Answer reason: Perioral numbness, tingling of fingers/toes, and muscle twitching are classic early neuromuscular irritability signs that can progress to carpopedal spasm and laryngospasm. This complication requires prompt recognition and typically treatment with calcium replacement and monitoring for airway compromise. In contrast, hemorrhage would present with neck swelling, increased drainage, and potential airway obstruction rather than distal paresthesias.

Question 12

While examining a 2-year-old child, the nurse in charge sees that the anterior fontanel is open. The nurse should?

Accepted Answer

Answer reason: Delayed closure can be associated with conditions such as hypothyroidism, rickets/vitamin D deficiency, increased intracranial pressure, or genetic syndromes, and warrants provider assessment and possible diagnostic workup. This finding alone is not specific for abuse, and suspicion of abuse should be based on a broader pattern of history and physical findings. Tay-Sachs disease is not a typical cause of delayed fontanel closure, so targeting that history does not address the most likely clinical concern.

Question 13

After a liver biopsy, place the patient in which of the following positions?

Accepted Answer

Answer reason: Placing the patient on the right side puts direct pressure on the biopsy site to reduce bleeding and help seal the tract. Keeping the bed flat decreases movement and abdominal muscle use that could disrupt clot formation and worsen bleeding. A semi-Fowler’s position can increase tension and movement at the puncture site, and left side-lying fails to provide local compression of the liver biopsy area.

Question 14

A priority nursing diagnosis for the client who is being discharged home 3 days after a TURP would be?

Accepted Answer

Answer reason: This diagnosis best captures the immediate post-procedure physiologic problem driving key discharge teaching (hydration to keep urine light pink, avoiding straining/heavy lifting, monitoring for bright red bleeding, fever, or inability to void). Fluid volume deficit is not typically the dominant risk at day 3 unless there is significant hemorrhage, and there are no cues provided to support that as the priority. Airway clearance and nutrition problems are not expected direct priorities related to the procedure in an otherwise stable discharge scenario.

Question 15

Nurse Amanda is caring for a client with severe blood loss who is prescribed multiple transfusions of blood. Nurse Amanda obtains which most essential piece of equipment to prevent the risk of cardiac dysrhythmias?

Accepted Answer

Answer reason: Warming blood to near body temperature reduces this iatrogenic cooling and helps maintain stable cardiac conduction, especially when multiple units are being infused. A cardiac monitor helps detect dysrhythmias early but does not prevent the physiologic trigger. An ECG machine provides intermittent diagnostic recording rather than continuous protection from temperature-related complications.

Question 16

A 3-year-old child is receiving dextrose 5% in water and half-normal saline solution at 100 ml/hour. Which sign or symptom suggests excessive I.V. fluid intake?

Accepted Answer

Answer reason: A key early clinical indicator is new or worsening respiratory distress (dyspnea), often accompanied by crackles and decreased oxygenation. Fever more strongly suggests infection or another inflammatory process rather than volume overload. Gastrointestinal symptoms like distension or nausea/vomiting are nonspecific and are less direct indicators of intravascular fluid excess compared with respiratory compromise.

Question 17

A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage, which may be shown by which of the following signs?

Accepted Answer

Answer reason: Frequent swallowing is a classic bedside sign that the client is swallowing blood draining down the throat, which can be subtle yet clinically important. This finding should prompt immediate assessment of the posterior pharynx, vital signs, and hemodynamic status, and rapid notification of the provider. Ear bleeding suggests basilar skull fracture/CSF-related trauma patterns rather than the expected postoperative drainage route for this procedure. Guaiac-positive stools and hematuria indicate gastrointestinal or urinary bleeding and are not the most direct early sign of hemorrhage related to the transsphenoidal surgical field.

Question 18

When instructing the female client diagnosed with hyperparathyroidism about diet, nurse Gina should stress the importance of which of the following?

Accepted Answer

Answer reason: Increasing oral fluid intake promotes diuresis and reduces urinary calcium concentration, lowering stone formation risk and helping protect kidney function. Fluid restriction would concentrate urine and worsen the likelihood of stones and hypercalcemia-related renal complications. Sodium and potassium restrictions are not the primary diet teaching for this condition compared with preventing hypercalcemia-related renal sequelae through adequate hydration.

Question 19

On a follow-up visit after having a vaginal hysterectomy, a 32-year-old patient has a decreased hematocrit level. Which of the following complications does this suggest?

Accepted Answer

Answer reason: A vaginal cuff or pelvic hematoma can conceal significant postoperative bleeding, leading to decreased hematocrit even without obvious external bleeding. Hypovolemia is a physiologic consequence of hemorrhage but is not as specific a “complication” diagnosis as an occult hematoma in this context. Infection and pulmonary embolus typically present with fever, localized signs, respiratory symptoms, or hemodynamic changes rather than an isolated drop in hematocrit.

Question 20

A client is receiving a radiation implant for the treatment of bladder cancer. Which of the following interventions is appropriate?

Accepted Answer

Answer reason: Internal radiation to the bladder can inflame and damage the urothelial mucosa, making radiation cystitis a common anticipated complication. Ongoing assessment for dysuria, frequency/urgency, suprapubic pain, hematuria, and fever enables early detection and prompt management to prevent worsening bleeding, obstruction, or infection. Fluid restriction would typically worsen urinary irritation and concentration of urine rather than protect the bladder. Room assignment and urine disposal are not the primary targeted intervention for preventing or detecting the most expected bladder-specific complication from this therapy.

Question 21

Hannah’s child is scheduled for surgery due to myelomeningocele; the primary reason for surgical repair is which of the following?

Accepted Answer

Answer reason: Early surgical closure primarily aims to cover the defect and create a protective barrier to minimize contamination and fluid leakage. While hydrocephalus is common (often due to associated Chiari II malformation), closing the lesion does not reliably prevent it and many infants still require shunting. Surgical repair also does not reverse pre-existing neurologic deficits; it mainly prevents further injury and infectious complications.

Question 22

Because of difficulties with hemodialysis, peritoneal dialysis is initiated to treat a female client’s uremia. Which finding signals a significant problem during this procedure?

Accepted Answer

Answer reason: A WBC of 20,000/mm3 is markedly elevated and, in the setting of an indwelling peritoneal catheter and dialysate exchanges, strongly suggests infectious complication rather than an expected procedural change. In contrast, a potassium of 3.5 mEq/L is within normal range, and an HCT of 35% is only mildly low and commonly seen with chronic kidney disease. While hyperglycemia can occur due to glucose-based dialysate, it is not as immediately specific for a serious dialysis-related complication as a significant leukocytosis suggesting infection.

Question 23

A vaginal exam reveals a footling breech presentation. The nurse should take which of the following actions at this time?

Accepted Answer

Answer reason: The knee-chest (genupectoral) position uses gravity to lift the fetus off the cervix, helping minimize cord compression if prolapse is present or imminent. Fetal monitoring is important but does not address the immediate mechanical risk, and definitive delivery planning (often cesarean) follows stabilization rather than preceding it. Ultrasound may confirm presentation, but the vaginal exam has already identified the presentation and delaying positioning could increase risk.

Question 24

Nurse Bea should instruct the male client with an ileostomy to report immediately which of the following symptoms?

Accepted Answer

Answer reason: Early recognition matters because obstruction can rapidly progress to abdominal distention, vomiting, severe fluid/electrolyte derangements, and ischemia if strangulation occurs. Liquid stool output and occasional undigested food are expected with an ileostomy due to reduced colonic water absorption and shorter transit time. A temperature of 37.6 °C is low-grade and not, by itself, as urgent as cessation of stoma output.

Question 25

A 72-year-old client with advanced osteoporosis is admitted after suddenly developing acute lower back pain while bending to pick up a bag of groceries. The client reports the pain as "sharp and shooting," radiating down the left leg. Assessment reveals positive straight leg raise test, limited mobility, and difficulty standing upright. The client also reports new urinary urgency that began a few hours ago. Which finding requires the nurse’s immediate priority action?

Accepted Answer

Answer reason: This requires immediate action because delayed recognition can lead to irreversible bowel/bladder dysfunction and lower-extremity weakness. Urinary urgency/new dysfunction is a key red-flag finding that prioritizes rapid provider notification and urgent diagnostic evaluation. By contrast, radicular pain and a positive straight leg raise are consistent with nerve root irritation but are not as time-critical as evolving bladder involvement.

Question 26

A 56-year-old client was admitted after a fall resulting in a closed tibial fracture. A long leg cast was applied 6 hours ago. The client now reports severe, unrelenting pain in the affected leg rated 10/10, despite receiving opioid analgesics. The nurse notes pale toes, delayed capillary refill, increasing paresthesia, and the client states, “My leg feels tighter and tighter.” Pedal pulses are weak but present. Which action should the nurse take FIRST?

Accepted Answer

Answer reason: This is a time-critical emergency requiring rapid provider evaluation for cast bivalving/removal and possible fasciotomy to prevent irreversible ischemia and nerve/muscle necrosis. Elevating above heart level can further reduce arterial inflow and worsen ischemia when compartment syndrome is suspected, so it is unsafe as a first action. Waiting to reassess delays definitive intervention, and ice may reduce swelling but does not address the escalating compartment pressure that is already compromising circulation and sensation.

Question 27

Nurse Chole is evaluating a female child with acute post-streptococcal glomerulonephritis for signs of improvement. Which finding typically is the earliest sign of improvement?

Accepted Answer

Answer reason: As renal perfusion and filtration improve, oliguria resolves first, leading to increased urine output and subsequent reduction in edema and hypertension risk. Appetite and energy commonly improve later as uremic symptoms and fluid overload abate. Diarrhea is not a typical defining manifestation of this condition, so its change is not a reliable indicator of recovery.

Question 28

A nurse is assessing a client post total thyroidectomy. Which finding is the priority for the nurse to report to the health care provider?

Accepted Answer

Answer reason: This can rapidly progress to neuromuscular irritability and laryngospasm, creating an immediate airway threat and need for IV calcium and close monitoring. This finding indicates severe calcium derangement rather than a mild, expected postoperative change. Muscle twitching can be an earlier sign of the same problem, but tetany represents a more urgent, advanced manifestation requiring prompt provider notification and treatment.

Question 29

A patient being treated for a right tibia/fibula fracture is requesting more pain medication. She is grimacing and states “It’s getting worse. It’s unbearable.” The nurse realizes the patient has already received the allowed scheduled and PRN doses. The best response by the nurse is?

Accepted Answer

Answer reason: Neurovascular checks (pain out of proportion, pallor, pulses, paresthesia, paralysis, poikilothermia) and swelling/tightness evaluation help identify limb-threatening ischemia early. Providing only reassurance or nonpharmacologic measures risks delaying recognition of an emergency that may require rapid provider notification and intervention. Reassessing pain relief is appropriate in general, but it does not address the priority safety concern of a potentially deteriorating extremity.

Question 30

Nursing Interventions for Patient on Cast?

Accepted Answer

Answer reason: The core nursing priority with a newly casted limb is early detection of neurovascular compromise because swelling under a rigid cast can rapidly progress to ischemia and compartment syndrome. This option lists the key assessment findings (pain out of proportion, paresthesia, pallor/discoloration, coolness, decreased pulse) and includes the critical action of immediate provider notification for time-sensitive intervention. Elevation and turning can be appropriate supportive measures, but they do not substitute for ongoing neurovascular checks and escalation when compromise is suspected. Monitoring for infection is important later, but vascular compromise is the more immediate limb-threatening complication after casting.

Question 31

A clinic nurse prepares a teaching plan for a client receiving an antineoplastic medication. When implementing the plan, the nurse should make which statement to the client?

Accepted Answer

Answer reason: Antineoplastic therapy commonly causes immunosuppression, increasing infection risk and altering vaccine safety and effectiveness. Live vaccines may be contraindicated, and even inactivated vaccines may need timing adjustments (e.g., around chemotherapy cycles) to improve immune response and reduce adverse effects. Therefore, patients should not independently obtain immunizations without prescriber guidance. A common unsafe distractor is taking aspirin PRN, because chemotherapy-related thrombocytopenia can increase bleeding risk with aspirin.

Question 32

A client has had a central venous catheter inserted in the subclavian vein for initiation of total parenteral nutrition (TPN) therapy. What assessment finding best indicates to the nurse that the client may have a pneumothorax?

Accepted Answer

Answer reason: A pneumothorax after subclavian central line placement reduces effective ventilation on the affected side, leading to impaired oxygenation. A low oxygen saturation is an early, objective sign that ventilation-perfusion mismatch is occurring and warrants immediate evaluation (e.g., lung auscultation and chest x-ray) for pneumothorax. Sharp chest pain can occur but is less specific and may be influenced by procedural discomfort. Redness and swelling suggest local infection or infiltration, and a rapid radial pulse is a nonspecific stress response that does not best indicate this complication.

Question 33

A client who takes numerous medications is being prepared for surgery. The nurse reviewing the client medication list is most concerned about which medication that increases surgical risk?

Accepted Answer

Answer reason: Steroids also impair wound healing and increase infection risk due to immunosuppression, which are major postoperative complications. This medication class commonly requires perioperative “stress-dose” steroid planning rather than routine holding. While sedative-hypnotics and oral hypoglycemics can affect anesthesia and glucose control, they are typically managed with perioperative timing adjustments and monitoring and are not as broadly complication-amplifying as systemic steroids.

Question 34

A client who underwent bronchoscopy 4 hours ago is ask ing for something to drink to ease a sore throat. The nurse obtains some juice for the client after noting which assess ment data?

Accepted Answer

Answer reason: After bronchoscopy, local anesthetic and sedation can blunt protective airway reflexes, creating a high aspiration risk with oral intake. The safest criterion for giving fluids is return of the gag and effective swallow reflex, indicating the airway can be protected. Normal respiratory rate or clear breath sounds do not confirm intact swallowing, and absence of hemoptysis relates more to bleeding complications than aspiration prevention. Therefore the nurse should wait to offer juice until protective reflexes have returned.

Question 35

The nurse is discharging to home a client with a new diagnosis of atrial fibrillation. The nurse should explain that onset of which symptom is most important to report to the healthcare provider?

Accepted Answer

Answer reason: Coughing up blood can indicate significant hemorrhage (e.g., pulmonary bleeding) and requires urgent evaluation and potential modification/holding of anticoagulants. By contrast, an irregular pulse is expected with this dysrhythmia and is usually managed through routine follow-up unless accompanied by severe symptoms (syncope, chest pain, dyspnea). Fatigue and low-grade symptoms are common and less immediately dangerous than evidence of active bleeding.

Question 36

A client with diverticular disease undergoes a colonoscopy. During an abdominal assessment, the nurse looks for which sign to indicate a possible complication of the procedure?

Accepted Answer

Answer reason: Peritoneal inflammation classically produces involuntary guarding and rebound tenderness on abdominal exam, making these findings high-priority indicators of a serious post-procedure complication requiring urgent evaluation. Diarrhea and nausea/vomiting can occur from bowel prep, sedation effects, or minor GI upset and are less specific for a dangerous complication. Local skin redness/warmth is not a typical indicator of an intraperitoneal complication from an endoscopic procedure.

Question 37

Before administering IV magnesium sulfate therapy to a client with preeclampsia, which set of parameters should the nurse consider as the highest priority?

Accepted Answer

Answer reason: Adequate urine output is essential because magnesium is renally excreted; oliguria allows accumulation and increases toxicity risk. Respiratory rate reflects early ventilatory compromise, and patellar reflexes provide an early neurologic sign of rising magnesium levels. Compared with routine vital signs, this triad most directly targets the specific, life-threatening complications the nurse must screen for before starting therapy.

Question 38

A client who underwent pelvic surgery the previous day has a Penrose drain placed in the lower abdomen. The nurse should take which action in the care of this wound drain?

Accepted Answer

Answer reason: A Penrose drain is an open, passive drain that allows continuous drainage onto the dressing, which places the surrounding skin at high risk for maceration and excoriation. Ongoing assessment of the peridrain skin and prompt protective measures (e.g., barrier products and appropriate dressing changes) reduce breakdown and secondary infection risk. Keeping bulky gauze to a minimum is not the priority because absorption and skin protection are often needed with open drainage. While unexpected large increases in drainage should be reported, routine care centers on preventing local tissue injury from constant moisture and drainage.

Question 39

A post-operative patient presents with a partial opening of their surgical incision along the suture line. This condition is known as?

Accepted Answer

Answer reason: The stem describes partial opening without protrusion of organs, which matches dehiscence. A key contrast is evisceration, which involves extrusion of abdominal contents through the wound and represents a more severe complication. Herniation refers to protrusion of tissue through a weakness (often later or beneath intact skin), and debridement is a treatment process to remove nonviable tissue, not a postoperative wound complication diagnosis.

Question 40

The nurse receives report from the previous shift. Which patient should be assessed first?

Accepted Answer

Answer reason: Urine output of 180 mL in 12 hours (15 mL/hr) is marked oliguria, suggesting acute kidney injury, severe hypovolemia, or obstructive uropathy, and it is especially concerning despite a diuretic that should increase output. This finding warrants immediate assessment of vital signs, volume status, intake/output accuracy, bladder distention, and possible need to notify the provider and obtain labs (e.g., creatinine, electrolytes). By contrast, a metallic taste with metronidazole is a common benign adverse effect, postprandial glucose of 140 mg/dL is expected for many patients, and no stool output 10 hours after new colostomy is often normal early post-op due to ileus.

Question 41

Nurse Lee, after carefully verifying the blood unit with a fellow nurse, is about to start a blood transfusion for her patient. Before proceeding, which assessment should Nurse Lee prioritize?

Accepted Answer

Answer reason: Baseline assessment is essential before initiating blood products so the nurse can quickly detect and compare early changes consistent with an acute transfusion reaction (e.g., fever, hypotension, tachycardia, respiratory changes). Vital signs immediately prior to starting the transfusion establish the reference point for required ongoing monitoring during the first critical minutes. Intake and output and skin turgor are supportive assessments for fluid status but do not provide the most immediate safety baseline for reaction detection. NPO status is not required for a routine blood transfusion and does not reduce the primary risk of transfusion-related complications.

Question 42

A 2-year-old child is being transported to the trauma center from a local community hospital for treatment of a burn injury that is estimated as covering more than 40% of the body. The burns are both partial- and full-thickness burns. The nurse is asked to prepare for the arrival of the child and gathers supplies, anticipating that which treatment will be prescribed initially?

Accepted Answer

Answer reason: The earliest priority after airway/breathing is aggressive fluid resuscitation guided by accurate urine output, which is the most practical bedside marker of renal perfusion in pediatrics. A Foley catheter allows strict hourly I&O measurement to titrate fluids and detect inadequate resuscitation promptly. NG decompression and topical antimicrobials are important but are not the initial, time-critical intervention for guiding resuscitation, and routine sedation is not a first-line emergent priority unless required for procedures.

Question 43

Nurse Kelly is caring for Mrs. Lewis, a 62-year-old female client with a tracheostomy who no longer requires continuous mechanical ventilation. As part of the weaning process, Nurse Kelly plans to plug the tracheostomy tube opening temporarily. For how long should she initially plug the tube to assess the client’s tolerance?

Accepted Answer

Answer reason: A 10–15 minute first trial allows assessment for early signs of intolerance such as increased work of breathing, stridor, tachycardia, desaturation, or anxiety while limiting risk if the client cannot compensate. Longer initial durations (e.g., 30–60 minutes or 1–2 hours) are typically advanced to only after the client demonstrates good tolerance to brief trials. A duration of only seconds is too short to meaningfully evaluate sustained airway patency and respiratory endurance.

Question 44

A client was brought to the emergency department after suffering a closed head injury and lacerations around the face due to a hit-run accident. The client is unconscious and has a minimal response to noxious stimuli. Which of the following assessment findings if observed after few hours, should be reported to the physician immediately?

Accepted Answer

Answer reason: This indicates a breach in the meninges, creating high risk for meningitis and potentially worsening intracranial injury, requiring urgent provider evaluation and diagnostic confirmation. By contrast, withdrawal to pain is a neurologic response that can be expected with depressed consciousness and is less immediately alarming than evidence of CSF leak. Minor eyelid bruising/edema or bleeding from superficial facial lacerations is typically local trauma and does not signal a life-threatening intracranial complication as directly.

Question 45

Nurse Lisa is supervising a nursing student who is caring for a patient with a thoracotomy and chest tube. She instructs the student to report specific findings immediately. Which finding requires the nurse's urgent attention?

Accepted Answer

Answer reason: The water-seal chamber should show tidaling with respiration, but continuous bubbling indicates an air leak in the system or from the patient, risking failure to re-expand the lung and potential worsening pneumothorax. This finding requires prompt assessment of all connections, the insertion site dressing, and the drainage system integrity to prevent respiratory compromise. By contrast, 10–15 mL/hr of drainage can be expected post-thoracotomy depending on timing and trends, and localized pain is common and managed with analgesia while monitoring for escalation. A dressing dated yesterday is a documentation/maintenance issue but is not as immediately life-threatening as a suspected air leak.

Question 46

A 30 y.o. female patient is undergoing hemodialysis with an internal arteriovenous fistula in place. What do you do to prevent complications associated with this device?

Accepted Answer

Answer reason: The key principle is to protect AV fistula patency by avoiding any external compression or venipuncture that can reduce flow and promote thrombosis. Inflating a BP cuff on the access arm can obstruct blood flow through the fistula and precipitate clotting or loss of the access. In contrast, a bruit and thrill are expected findings indicating flow; the concern is absence of these, not their presence. Starting IVs in that extremity is also avoided, so choosing the option that explicitly prevents compression is the best single answer.

Question 47

The client newly diagnosed with chronic renal failure recently has begun hemodialysis. Knowing that the client is at risk for disequilibrium syndrome, the nurse assesses the client during dialysis for?

Accepted Answer

Answer reason: Dialysis disequilibrium syndrome is caused by rapid solute (urea) removal during hemodialysis, creating an osmotic gradient that drives water into brain tissue and leads to cerebral edema. This produces acute neurologic findings such as headache, confusion/decreasing LOC, myoclonus/twitching, and can progress to seizures. The option with clustered CNS symptoms best matches this complication during early dialysis treatments. The vital-sign–focused options are more consistent with infection or volume shifts rather than the hallmark neurologic presentation of disequilibrium syndrome.

Question 48

The client with chronic renal failure returns to the nursing unit following a hemodialysis treatment. On assessment the nurse notes that the client’s temperature is 100.2. Which of the following is the most appropriate nursing action?

Accepted Answer

Answer reason: A new fever after hemodialysis raises concern for a dialysis-related complication such as access infection or bacteremia, which can progress quickly in an immunocompromised renal-failure client. Prompt provider notification is appropriate so that urgent evaluation, cultures, and antimicrobial therapy can be initiated as needed. Simply continuing routine monitoring delays escalation of care when early sepsis may be developing. Encouraging fluids is inappropriate after dialysis because fluid intake is commonly restricted and can worsen volume overload; assessing the shunt is important but does not replace immediate reporting of a post-dialysis fever.

Question 49

A male client in the short-procedure unit is recovering from renal angiography in which a femoral puncture site was used. When providing post-procedure care, the nurse should?

Accepted Answer

Answer reason: After femoral arterial access, the key risk is vascular compromise distal to the puncture (arterial spasm, thrombus, hematoma/retroperitoneal bleed affecting perfusion). Frequent neurovascular checks—especially distal pulses, temperature, color, capillary refill, and sensation—allow early detection of impaired circulation requiring urgent intervention. The affected leg should be kept straight with limited hip/knee flexion to reduce bleeding risk, making the bent-knee instruction unsafe. Manual pressure duration is typically shorter and/or replaced by closure devices, and dressings are not removed solely because vital signs stabilize since the priority is monitoring and preventing hemorrhage/ischemia.

Question 50

A client is scheduled to undergo a transurethral resection of the prostate gland (TURP). The procedure is to be done under spinal anesthesia. Postoperatively, the nurse should be particularly alert for early signs of?

Accepted Answer

Answer reason: Early recognition is critical because respiratory depression can progress rapidly and requires immediate airway/ventilatory support. Although hypotension and bradycardia are common with sympathetic blockade, respiratory compromise is the key early danger sign that signals an excessively high block. The other options are not the characteristic early postoperative complication specifically linked to an excessive spinal level after TURP under spinal anesthesia.

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