Question 1

A client underwent a TURP, and a large three-way catheter was inserted into the bladder with continuous bladder irrigation. In which of the following circumstances would the nurse increase the flow rate of the continuous bladder irrigation?

Accepted Answer

Answer reason: The key principle is that continuous bladder irrigation after TURP is titrated to maintain a light pink output and prevent clot formation that can obstruct the catheter. Bright red drainage indicates increased bleeding, so increasing the irrigation rate helps flush blood and small clots from the bladder and reduces the risk of retention and tamponade. In contrast, absent drainage suggests possible obstruction or kinking and requires immediate assessment and likely manual irrigation rather than simply increasing the rate, which can worsen bladder distention. Slow but continuous drainage or cloudy/dark yellow urine does not indicate active hemorrhage requiring higher irrigation flow.

Question 2

A 54-year-old client with type 2 diabetes and peripheral arterial disease presents with a non-healing ulcer on the right great toe. The ulcer has a pale wound bed, minimal drainage, and the surrounding skin is cool and shiny. The client reports intermittent leg pain that worsens when walking and improves when the leg is placed in a dependent position. Pedal pulses are faint and difficult to palpate, and capillary refill is delayed. Which nursing action is the highest priority?

Accepted Answer

Answer reason: The priority nursing action is to escalate care so diagnostic evaluation and medical/surgical interventions to restore perfusion can be initiated promptly. Elevation above the heart can further reduce arterial flow and worsen ischemic pain, and aggressive ambulation can increase oxygen demand and exacerbate ischemia. Warm moist compresses are not a definitive or safe priority intervention and may increase risk of burns in a diabetic client with reduced sensation.

Question 3

Nurse Paulo has received a blood unit from the blood bank and has rechecked the blood bag properly with nurse Edward. Prior to the facilitation of the blood transfusion, nurse Paulo priority checks which of the following?

Accepted Answer

Answer reason: Baseline assessment is essential before initiating any blood transfusion to detect early and potentially fatal transfusion reactions. Checking temperature, pulse, respirations, blood pressure, and oxygen saturation immediately before starting provides a comparison point for changes such as fever, hypotension, tachycardia, or respiratory distress. If abnormal findings are present, the transfusion may need to be delayed and the provider notified to reduce risk. Intake/output and skin turgor assess fluid status but do not provide the most immediate safety baseline for acute transfusion reactions.

Question 4

The nurse is changing the ties of the client with a tracheostomy. The safest method of changing the tracheostomy ties is to?

Accepted Answer

Answer reason: The key safety principle is preventing accidental decannulation and immediate airway compromise during tie changes. A second person can stabilize the tracheostomy tube/faceplate while the nurse removes and replaces ties, minimizing movement and allowing rapid response if the tube dislodges. This is especially important in a newer or unstable tracheostomy where reinsertion may be difficult and hypoxia can occur quickly. While securing the new tie before removing the old and stabilizing the tube are good technique elements, the presence of a helper is the single best safety measure because it provides continuous stabilization plus backup for emergent airway management.

Question 5

A client is prescribed with Pentamidine (Pentam) IV for the treatment of Pneumocystis carinii pneumonia. Suddenly, the client develops a temperature of 101.5°F. The nurse in charge knows that this sign would mostly indicate which of the following?

Accepted Answer

Answer reason: A new fever during antimicrobial therapy is a red-flag change that most strongly suggests an additional or worsening infectious process rather than a desired drug response. Clients treated for Pneumocystis pneumonia are often immunocompromised, increasing risk for concurrent opportunistic or secondary bacterial infections that can present with abrupt temperature elevation. Fever is not an expected indicator of therapeutic effectiveness, and “additional dosage” is not guided by a sudden febrile spike without further assessment. While medications can cause drug fever, the most clinically likely and safety-relevant interpretation in this context is new infection requiring prompt evaluation (cultures, assessment, and provider notification).

Question 6

During the client’s dialysis, the nurse observes that the solution draining from the abdomen is consistently blood-tinged. The client has a permanent peritoneal catheter in place. Which interpretation of this observation would be correct?

Accepted Answer

Answer reason: Persistent blood-tinged peritoneal dialysate is an abnormal finding that suggests trauma or irritation within the peritoneal cavity rather than a normal expected outcome. With a permanent peritoneal catheter, ongoing bleeding most concerningly reflects injury to abdominal/peritoneal vessels or catheter-related tissue trauma and warrants prompt assessment and provider notification. Kidney injury would not typically present as blood in drained peritoneal effluent because the fluid is coming from the peritoneal cavity, not the urinary tract. A common benign exception is mild transient pink effluent (e.g., early after catheter insertion or during menstruation), but “consistently” blood-tinged drainage points to a complication.

Question 7

Nurse Oliver is attending to a child with Cushing’s syndrome. Which of the following nursing interventions would be most necessary?

Accepted Answer

Answer reason: Gentle handling, avoiding unnecessary venipunctures/adhesive trauma, and protecting the skin directly addresses a high-likelihood complication. While hypertension monitoring is important, it is an assessment rather than the most immediate protective intervention against common daily-care harm. Hypoglycemia and metabolic acidosis are not typical expected complications of Cushing’s; hyperglycemia is more characteristic.

Question 8

Tiffany is diagnosed with increased intracranial pressure (ICP); which of the following if stated by her parents would indicate a need for Nurse Charlie to reexplain the purpose for elevating the head of the bed at a 10 to 20-degree angle?

Accepted Answer

Answer reason: Raising intrathoracic pressure impedes venous return via the jugular veins, which can increase cerebral venous congestion and worsen ICP rather than improve it. Maintaining a neutral head/neck position supports unobstructed jugular venous outflow and aligns with this intervention’s purpose. A common misconception is that any elevation improves ICP regardless of other pressures; however, measures that increase thoracic or abdominal pressure can counteract the intended cerebral drainage benefit.

Question 9

Annabelle is being discharged with a colostomy, and you’re teaching her about colostomy care. Which statement correctly describes a healthy stoma?

Accepted Answer

Answer reason: ” A newly created stoma is made of highly vascular mucosal tissue, so minimal oozing with gentle cleansing or manipulation can be expected early on. A healthy stoma is typically moist and pink to red; dusky, dark, or bluish coloration suggests impaired perfusion/ischemia and requires urgent evaluation. Burning under the faceplate indicates peristomal skin irritation or leakage rather than a normal finding. Post-op edema should gradually decrease; persistent marked swelling/protrusion can signal complications such as stomal edema, prolapse, or obstruction risk.

Question 10

The nurse reviews the nurse’s notes from 1530 hrs to 1600 hrs. What should be the nurse’s priority intervention?

Accepted Answer

Answer reason: In acute pediatric respiratory conditions treated with a short-acting bronchodilator, the immediate priority is ongoing assessment for deterioration or inadequate response because airway and ventilation problems can worsen rapidly. Frequent reassessment of work of breathing, breath sounds, wheeze/air entry, oxygen saturation, and ability to speak/feed guides whether escalation is needed. Giving an additional bronchodilator dose or calling the provider may be appropriate, but both depend on reassessment findings and standing orders; monitoring is the safest first step when the next action is unclear. Preparing for discharge is premature without documented sustained stability and absence of rebound symptoms after treatment.

Question 11

A nurse is caring for a client with congestive heart failure on furosemide and a potassium level of 2.8mmol/L. Which action should the nurse take first?

Accepted Answer

Answer reason: 8 mmol/L) increases myocardial irritability and can rapidly precipitate dysrhythmias, especially in a client with heart failure receiving a loop diuretic. The priority “first” action is immediate surveillance for life-threatening complications by initiating continuous cardiac monitoring. Potassium replacement and medication changes are important, but they are not as time-critical as detecting and responding to an evolving arrhythmia. Notifying the provider may be appropriate depending on protocols, but monitoring is an immediate independent nursing action that addresses the highest-risk complication right now.

Question 12

A nurse is caring for a client admitted with suspected appendicitis. Which of the following actions should the nurse avoid to ensure patient safety and prevent complications?

Accepted Answer

Answer reason: In suspected appendicitis, nursing care focuses on preventing perforation while preparing for possible surgical management. Keeping the client NPO and starting IV fluids are appropriate to support hydration and readiness for anesthesia. Close monitoring for worsening pain and rigidity is essential because these can signal perforation requiring urgent intervention.

Question 13

A child is admitted with a head injury after being in a motor vehicle crash. After noting the presence of clear drainage from the left ear, the nurse should suspect which underlying problem commonly associated with this finding?

Accepted Answer

Answer reason: Basilar skull fractures commonly involve the temporal bone and can disrupt the dura, allowing CSF to escape via the ear or nose. This finding signals increased risk for complications such as meningitis and requires prompt evaluation and precautions (e.g., avoid packing the ear). In contrast, epidural and subdural hematomas primarily present with signs of intracranial bleeding and rising ICP rather than isolated clear otorrhea.

Question 14

Which statement made by a client who has chronic kidney disease and is on hemodialysis indicates the need for further teaching?

Accepted Answer

Answer reason: Many salt substitutes contain potassium chloride, and patients with chronic kidney disease are at high risk for hyperkalemia because they cannot excrete potassium effectively. Using these products can precipitate dangerous dysrhythmias and neuromuscular symptoms, so they should be avoided unless specifically approved and monitored. In contrast, monitoring for rapid weight gain and protecting the AV fistula reflect appropriate self-management to reduce fluid overload and access complications. Antihypertensive adherence is also generally appropriate to control blood pressure and slow further renal/cardiovascular complications, with provider guidance around dialysis days.

Question 15

The nursing instructor is going over burn injuries. The instructor tells the students that the nursing care priorities for a patient with a burn injury include wound care, nutritional support, and prevention of complications such as infection. Based upon these care priorities, the instructor is most likely discussing a patient in what phase of burn care?

Accepted Answer

Answer reason: This phase begins after fluid resuscitation is stabilized and continues until wound closure or grafting is complete. Wound care interventions (debridement, topical antimicrobials, dressing changes, graft care) and complication monitoring are central because the loss of skin barrier and hypermetabolic response drive infection risk and nutritional needs. In contrast, the emergent/resuscitative period is dominated by airway protection and aggressive fluid replacement rather than extensive wound care planning and nutritional rebuilding.

Question 16

The nurse is aware that the client who underwent gastric lavage for overdose of a prescribed medication will need careful assessment for treatment complications. Which assessment should be the nurse’s priority?

Accepted Answer

Answer reason: Monitoring respirations and auscultating lung sounds best detects early aspiration (new crackles/wheezes), decreased air movement, or evolving respiratory distress that requires immediate intervention. While vital signs are important, hemodynamic changes may occur later and are less specific for the most time-critical lavage complication. Early recognition of aspiration-related changes reduces the risk of respiratory failure and pneumonia.

Question 17

The nurse determines that the client with Ewing’s sarcoma understands instruction about side effects of radiation therapy when the client states to be concerned about which problem?

Accepted Answer

Answer reason: This is a clinically important adverse effect because radiation therapy can cause bone marrow suppression, increasing the client’s risk for infection. Infection is a priority concern due to its potential severity and rapid progression in immunocompromised patients.

Question 18

An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first?

Accepted Answer

Answer reason: Rising ICP is initially managed by optimizing cerebral venous outflow and preventing secondary brain injury with low-risk, immediately reversible measures. Neck flexion can obstruct jugular venous drainage, increasing intracranial blood volume and worsening ICP, so maintaining neutral head/neck alignment is a priority bedside action. Osmotic diuretics and barbiturates may be appropriate if prescribed, but they are higher-risk and typically follow rapid positioning/airway and hemodynamic optimization. Increasing ventilator rate to induce hypocapnia causes cerebral vasoconstriction and can reduce ICP short-term, but routine hyperventilation is avoided unless there are signs of impending herniation and it requires careful monitoring.

Question 19

A client has just returned to a nursing unit after a cardiac catheterization performed using the femoral artery. The nurse places the client in which position?

Accepted Answer

Answer reason: After femoral-artery catheterization, the priority is preventing bleeding and hematoma at the puncture site by minimizing hip flexion and reducing pressure changes at the groin. Keeping the client on bed rest with only slight head-of-bed elevation helps maintain a straight leg and limits strain on the arterial access site while still supporting comfort and airway. Higher head elevations increase hip flexion, which can disrupt hemostasis and lead to oozing or retroperitoneal bleeding. Ongoing neurovascular checks and frequent assessment of the dressing and distal pulses accompany this positioning to detect complications early.

Question 20

Which of the following statements is true regarding jaundice in newborns?

Accepted Answer

Answer reason: Phototherapy uses light to isomerize bilirubin in the skin, but it can injure sensitive tissues if unprotected. Standard nursing safety measures include shielding the eyes to prevent retinal damage and protecting the gonads/genitals to reduce unnecessary exposure. This directly addresses preventing treatment-related complications during a common neonatal therapy. A key distractor is the claim that jaundice in the first 24 hours is physiologic; jaundice that early is abnormal and warrants evaluation for hemolysis or other pathology.

Question 21

The nurse is caring for a client admitted with spinal cord injury. The nurse minimizes the risk of compounding the injury most effectively by?

Accepted Answer

Answer reason: This device provides rigid, continuous support and allows safe turning (supine-to-prone) without twisting or flexing the spine, which reduces the chance of worsening cord compression. It also facilitates frequent repositioning and skin care while keeping the spine stabilized, lowering complication risk during acute management. Logrolling helps but still carries risk of subtle rotation/shift, and a soft mattress increases sinking and misalignment. Keeping a client on a stretcher is not a definitive stabilization strategy and does not optimize long-term immobilization and turning needs.

Question 22

A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning?

Accepted Answer

Answer reason: Endotracheal lidocaine is used to blunt the cough/gag reflex and attenuate this hemodynamic response before suctioning in patients at risk for increased ICP. Mannitol and furosemide lower ICP through osmotic/diuretic mechanisms but are not given specifically as immediate pre-suction measures to prevent the suction-induced spike. Phenytoin is for seizure prophylaxis after head injury and does not address the acute reflex ICP rise from suctioning.

Question 23

After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client?

Accepted Answer

Answer reason: In suspected severe traumatic brain injury with signs of markedly increased intracranial pressure (coma and nonreactive pupils), procedures that can acutely change pressure gradients between intracranial and spinal compartments can precipitate brain herniation. A lumbar puncture can rapidly lower spinal CSF pressure, worsening downward displacement of brain tissue when ICP is elevated. Mechanical ventilation, head-of-bed elevation, and (when indicated) sedatives such as barbiturates are commonly used components of ICP management rather than immediate high-risk precipitants of herniation. Therefore, this intervention poses the greatest immediate danger in this presentation.

Question 24

Among the topics you will include as priority in health teaching to Mario is?

Accepted Answer

Answer reason: Teaching focused on daily inspection, hygiene, proper footwear, and prompt reporting of breaks in skin directly reduces preventable morbidity. This is a concrete, high-yield self-care behavior with immediate safety impact compared with broad advice like exercise or diet. While nutrition and activity are important for long-term glycemic control, preventing foot-related injury addresses a frequent, serious complication through specific daily actions. The priority is therefore risk-reduction teaching aimed at avoiding severe downstream complications.

Question 25

Which nursing measure takes priority in relation to the care of a patient with a gastroesophageal balloon tube?

Accepted Answer

Answer reason: A gastroesophageal balloon tube (e.g., Sengstaken-Blakemore) creates a high risk of airway obstruction and aspiration if the tube migrates or if secretions/vomitus are not cleared. The priority is early detection of hypoxia or respiratory compromise through frequent assessment of breathing, oxygenation, and level of consciousness. Periodic balloon deflation is not routine and can precipitate rebleeding, and tube advancement/repositioning should be done only per provider protocol because malposition can worsen obstruction. Sedating or restraining restlessness without addressing airway risk can mask deterioration and increase aspiration risk.

Question 26

Which instruction should be given to a patient with portal hypertension to reduce the threat of hemorrhage?

Accepted Answer

Answer reason: Portal hypertension increases venous pressure in collateral vessels (especially esophageal/gastric varices), making them prone to rupture with sudden rises in intra-abdominal and intrathoracic pressure. Straining during defecation (Valsalva maneuver) acutely elevates these pressures and can precipitate variceal bleeding. Reducing constipation and avoiding straining is therefore a key hemorrhage-prevention instruction. Using an electric razor addresses bleeding risk from minor cuts but does not target the primary life-threatening hemorrhage risk in portal hypertension (variceal rupture).

Question 27

A nurse is caring for a 10 year old child who has acute glomerulonephritis. Which of the following findings should the nurse report to the provider?

Accepted Answer

Answer reason: Acute glomerulonephritis can reduce glomerular filtration, causing oliguria and rapid fluid overload with rising uremic toxins. A 24-hour urine output of 550 mL for a school-age child is concerning for oliguria and suggests worsening renal perfusion/filtration that needs provider evaluation and possible escalation of care. The blood pressure listed is not hypertensive for this age, so it is less concerning for complications like hypertensive encephalopathy. A BUN of 8 mg/dL is within/near normal and does not indicate azotemia, while the creatinine value is only mildly elevated compared with the immediate safety concern of low urine output.

Question 28

The nurse is reassessing her patient diagnosed with appendicitis. The patient expressed 8/10 pain at her last assessment, and now states she has no pain. The nurse did not administer any pain medication. What is the appropriate nursing action?

Accepted Answer

Answer reason: This change represents a significant deterioration risk that requires rapid medical evaluation and likely urgent surgical management rather than routine reassessment alone. Immediate escalation supports early recognition and treatment of peritonitis/sepsis risk. Simply documenting or doing additional focused palpation can delay definitive care and may worsen pain or spread inflammation; abdominal assessment is important but does not replace prompt provider notification when a red-flag change occurs.

Question 29

The nurse is caring for a client who suffered a spinal cord injury 48 hours ago. The nurse monitors for GI complications by assessing for?

Accepted Answer

Answer reason: Acute spinal cord injury can precipitate GI complications from stress response and impaired autonomic regulation, increasing risk for stress-related mucosal bleeding. Testing nasogastric drainage for occult blood is a direct, early indicator of upper GI bleeding and potential hemodynamic deterioration that requires prompt intervention. Hyperactive bowel sounds and diarrhea are less characteristic in the first 48 hours, when decreased motility/ileus is more typical. A flattened abdomen is nonspecific and does not specifically screen for serious GI bleeding complications.

Question 30

A 23-year-old client has been hit on the head with a baseball bat. The nurse notices clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first?

Accepted Answer

Answer reason: Testing the drainage for glucose helps differentiate CSF from other secretions and guides urgent escalation of care and precautions. Inserting packing or suctioning the nares can increase infection risk and may worsen injury by disrupting tissue and promoting intracranial contamination. Flat positioning is not prioritized and can impede drainage or compromise safety; the immediate priority is to identify the suspected CSF leak and initiate appropriate precautions and notification.

Question 31

In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when positioning the client?

Accepted Answer

Answer reason: Head-of-bed elevation can promote venous and CSF drainage changes that increase the risk of postoperative complications in this location, so it is avoided unless specifically prescribed. Keeping the head midline and turning the client as a unit helps maintain cervical alignment and minimizes sudden intracranial pressure shifts. Side-lying with careful alignment is typically used to support airway and reduce aspiration risk while protecting the surgical site and neurologic status.

Question 32

The nurse is caring for a postoperative patient with chronic obstructive pulmonary disease (COPD). Which assessment would be a cue to the patient developing postoperative pneumonia?

Accepted Answer

Answer reason: A shift in sputum color/consistency suggests increased lower-airway secretions and bacterial infection rather than baseline COPD mucus. Hypoventilation with respiratory acidosis can occur from opioids or retained CO2 in COPD and is not specific for pneumonia. Pursed-lip breathing is a compensatory COPD technique to reduce air trapping and does not indicate a new infectious complication.

Question 33

The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid?

Accepted Answer

Answer reason: Turning the head can kink or compress the jugular veins, impeding venous outflow from the brain and thereby increasing intracranial blood volume and pressure. Standard positioning to support ICP control includes keeping the head midline with the neck neutral and elevating the head of bed about 30–45 degrees to promote venous return. Options that preserve alignment and venous drainage are therefore preferred over head rotation.

Question 34

A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid?

Accepted Answer

Answer reason: CSF contains measurable glucose, unlike typical nasal secretions, so a glucose-positive test supports that the drainage is CSF. When mixed with a small amount of blood, CSF produces the classic “halo” or concentric ring pattern on absorbent material due to differential diffusion. Findings like negative glucose or nonspecific pH values are not reliable indicators of CSF and can mislead assessment.

Question 35

The nurse is caring for a client with a fractured left tibia and fibula. Which data should the nurse report to the health-care provider (HCP) immediately?

Accepted Answer

Answer reason: Severe, persistent pain out of proportion to the injury is a red-flag sign for acute compartment syndrome after long-bone fractures and requires urgent evaluation to prevent ischemia and permanent neuromuscular damage. This finding suggests rising compartment pressures compromising tissue perfusion even before late neurovascular changes occur. In contrast, ecchymosis is expected with fractures, and capillary refill of 2 seconds and a 2+ pedal pulse are reassuring and do not exclude early compartment syndrome. Prompt provider notification supports rapid assessment and potential fasciotomy.

Question 36

A patient with Addison's disease is making a list of foods that will help him manage his condition and shows the nurse the list. Which of the following foods would the nurse find the most concerning? Select one?

Accepted Answer

Answer reason: Dietary teaching therefore emphasizes limiting high-potassium foods to reduce the likelihood of dysrhythmias and other complications. Potatoes are a notably potassium-rich food compared with the other listed vegetables, so they raise the most immediate concern on the patient’s list. A common pitfall is focusing only on sodium replacement; potassium restriction is also a key safety point in adrenal insufficiency management.

Question 37

After a transurethral resection of the prostate (TURP), the nurse noticed that the client's urine is bright red, has numerous clots and is viscous. Which nursing action is MOST appropriate?

Accepted Answer

Answer reason: Bright red, thick urine with many clots after TURP suggests active postoperative hemorrhage and potential catheter obstruction, which can quickly progress to urinary retention and shock. The priority is rapid assessment for hemodynamic instability (blood pressure, heart rate, signs of hypovolemia) and prompt escalation because ongoing bleeding may require urgent medical/surgical management or adjustment of continuous bladder irrigation. Irrigation may be ordered/used to maintain patency, but independently attempting to remove clots can delay recognition of significant bleeding and definitive treatment. Vigorous milking is contraindicated because it can increase trauma/bleeding, and increasing oral fluids is too slow and does not address acute hemorrhage.

Question 38

A patient underwent gastric procedure. The nurse provides post-operative care and an hour after the operation the patient's a face becomes pale and she is distressed. She reports feeling nauseous and requests a vomit bowl. The nurse notes that she frequently pushes the button of the patient-controlled analgesia pump?

Accepted Answer

Answer reason: A nasogastric tube is often placed to prevent vomiting and protect the surgical site by draining gastric contents; if it is kinked, clogged, or displaced, nausea can rapidly worsen. The frequent PCA button pressing may reflect uncontrolled visceral discomfort from distention rather than inadequate opioid dosing. Giving an antiemetic may reduce symptoms but does not address the likely mechanical cause and could delay recognition of a developing postoperative complication.

Question 39

Following abdominal surgery, a child has a nasogastric tube connected to suction. Several hours after surgery, the child tells the nurse that he is nauseated and then vomits approximately 200 ml of fluid. Which of these actions should the nurse take first?

Accepted Answer

Answer reason: The first priority is to stop the suction apparatus connection to prevent ongoing negative pressure issues and allow rapid assessment of patency and patient stability. After addressing the immediate safety risk, the nurse can troubleshoot the tube (e.g., assess placement/patency and consider irrigation per order/policy) and then notify the provider as needed. Simply auscultating bowel sounds does not address the acute complication risk associated with vomiting and a potentially non-functioning decompression system.

Question 40

The female client has been taking infertility medications. Which signs/symptoms would indicate ovarian overstimulation syndrome?

Accepted Answer

Answer reason: Ovarian hyperstimulation syndrome is a complication of fertility therapy characterized by increased vascular permeability with third-spacing of fluid into the peritoneal cavity. Ascites produces abdominal distention and can be detected clinically by a fluid wave, making this finding more specific for significant OHSS than nonspecific GI upset. Bright red vaginal bleeding is not a typical defining sign of OHSS and suggests an alternate gynecologic problem. Urinary frequency is more consistent with uncomplicated pelvic pressure or UTI, whereas OHSS more often causes decreased urine output from intravascular volume depletion and reduced renal perfusion.

Question 41

A 5-year-old has just had a tonsillectomy and adenoidectomy. Which of these nursing measures should be included in the postoperative care?

Accepted Answer

Answer reason: Post-tonsillectomy/adenoidectomy care prioritizes early detection of hemorrhage, a potentially rapid and life-threatening complication. Monitoring for frequent swallowing, hematemesis, tachycardia, pallor, or restlessness supports prompt intervention before airway compromise or shock develops. Encouraging coughing or gargling/toothbrushing can dislodge clots and increase bleeding risk. Warm liquids are not preferred initially; cool clear fluids are typically better tolerated and may reduce discomfort and bleeding risk once the child is fully awake.

Question 42

The nurse is caring for a client with a chest tube for the treatment of a pneumothorax. Which item is essential to have at the bedside?

Accepted Answer

Answer reason: A key safety principle with chest tubes is preventing air from entering the pleural space if the drainage system becomes disconnected, which could recreate or worsen a pneumothorax. Sterile water allows the nurse to immediately place the chest tube end into water to re-establish a temporary water seal until the system can be reconnected or replaced. This is an urgent bedside contingency item because accidental disconnection can happen suddenly during movement or care. Oxygen may be supportive but does not address the mechanical risk of loss of the water seal, and the other items are unrelated to chest tube emergencies.

Question 43

A client who has had a laparoscopic examination 4 hours ago is complaining of upper abdominal pain radiating to the shoulder. The nurse should realize that the client's pain is most likely?

Accepted Answer

Answer reason: This is common in the first hours to days post-procedure and typically improves with ambulation, repositioning, and analgesia. Visceral perforation would more often present with worsening abdominal pain, guarding/rigidity, fever, tachycardia, or signs of peritonitis rather than isolated shoulder-tip pain. Retained gallstones or contrast dye reaction would be tied to biliary procedures and would more likely include jaundice/colicky RUQ pain or allergic features (urticaria, bronchospasm, hypotension).

Question 44

A client with heart failure will take oral furosemide at home. To help the client evaluate the effectiveness of furosemide therapy, the nurse should teach the client to?

Accepted Answer

Answer reason: Diuretics in heart failure are used primarily to reduce fluid volume overload, and the most sensitive, practical home measure of changing fluid status is daily weight. A 1 kg (2.2 lb) weight change in 24 hours approximates about 1 liter of fluid gain or loss, allowing early detection of worsening congestion or inadequate diuresis. Blood pressure monitoring is useful for safety but does not directly quantify decongestion, and urine output records are often inaccurate and impractical in the home setting. Potassium monitoring is important for adverse-effect surveillance, but it evaluates safety rather than day-to-day effectiveness of fluid removal.

Question 45

A nurse is completing discharge teaching to the parent of a child who is postoperative following a tonsillectomy. Which finding should be reported as a priority?

Accepted Answer

Answer reason: Repeated swallowing (often with throat clearing) is a classic early sign of oozing/bleeding into the oropharynx and can precede vomiting of bright red blood. Ear pain and foul breath are expected referred pain/normal postoperative findings, and a mild temperature elevation can occur with dehydration and inflammation. Therefore this finding should be reported immediately for prompt assessment and intervention.

Question 46

The oncology nurse expects to see which of the following side effects when assessing a patient on chemotherapy?

Accepted Answer

Answer reason: This leads to a decreased absolute neutrophil count, making neutropenia a classic expected adverse effect that drives key monitoring and protective interventions. While infections can occur as a consequence, the direct side effect to anticipate on assessment is the low neutrophil count itself. Thrombocythemia and leukocytosis are opposite of the typical bone-marrow suppression pattern seen with most chemotherapy regimens.

Question 47

Which immediate complication should the nurse assess for in a client with a newly placed left leg cast?

Accepted Answer

Answer reason: The nurse’s immediate priority is frequent neurovascular assessment for the “6 Ps” (pain out of proportion, pallor, paresthesia, paralysis, pulselessness, poikilothermia) because delayed recognition can lead to permanent nerve/muscle damage and limb loss. This complication can develop within hours after casting and requires urgent intervention (e.g., loosening/bivalving the cast and possible fasciotomy). Constipation and loss of appetite may occur with immobility or opioids but are not limb-threatening emergencies, and sepsis is not a typical immediate cast-related complication without an infectious source.

Question 48

A nurse is caring for an adolescent client who has a fractured right tibia and a cast. Which of the following findings should the nurse report to the provider?

Accepted Answer

Answer reason: Distal coolness indicates impaired circulation and requires prompt provider notification for urgent assessment and possible cast bivalving or other interventions. In contrast, itching under a cast and dependent swelling are common, expected discomforts that are typically managed with teaching (avoid inserting objects; elevate the limb). Mild pain after prescribed range-of-motion can occur and is not as concerning as objective signs of decreased perfusion.

Question 49

Post operative position given after stapedectomy-?

Accepted Answer

Answer reason: Positioning the client with the operative (affected) ear up avoids direct compression and reduces the risk of disturbing the graft/packing. This also helps limit vertigo and nausea that can be worsened by pressure changes in the middle ear. Prone positioning is unnecessary and may increase discomfort and risk, while a generic “lateral” option is incomplete without specifying the non-operative side down.

Question 50

The nurse is teaching a client who has a peripherally inserted central catheter (PICC) and will be receiving total parenteral nutrition (TPN). The nurse should teach the client to notify the primary health care provider immediately if the client has?

Accepted Answer

Answer reason: Localized pain/tenderness tracking up the vein proximal to the insertion site is a key warning sign that the line may be irritating the vessel or that a clot is forming. By contrast, mild itching under a dressing more commonly reflects adhesive sensitivity and is typically non-urgent unless accompanied by signs of infection. Rapid identification and escalation helps prevent loss of line patency, sepsis, and thromboembolic complications while the client is receiving hyperosmolar TPN.

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