Question 1

A client returns to the nursing unit after placement of a nephrostomy tube. What is an appropriate action by the nurse when caring for this client?

Accepted Answer

Answer reason: Nephrostomy tubes require unobstructed drainage to prevent backflow, hydronephrosis, infection, and loss of renal function. Checking that tubing is not kinked and that dependent loops are avoided is a first-line nursing action to maintain continuous urine flow and promptly address decreased output. Attaching a bag to the bedrail is unsafe because rail movement can tug on the tube and dislodge it; the bag should be secured to the bed frame below kidney level. Routine hourly irrigation is not performed unless specifically prescribed, because it can introduce infection or increase pressure within the collecting system.

Question 2

A neonate is born with exstrophy of the bladder. Which intervention would be appropriate for the nurse to complete first?

Accepted Answer

Answer reason: A sterile, nonadherent, moisture-retaining dressing helps maintain tissue viability and reduces bacterial contamination risk. Catheter insertion is not the first action because manipulation can injure exposed tissue and does not address desiccation risk. Surgery is required but is not the nurse’s first priority compared with promptly protecting the organ at the bedside.

Question 3

When caring for a client with a left radial artery catheter, which assessment data obtained by the nurse indicates the need to take immediate action?

Accepted Answer

Answer reason: A cooler extremity compared with the contralateral side is a key sign of impaired arterial blood flow and is more concerning than normal capillary refill alone because temperature change can precede more obvious findings. A MAP of 65 mm Hg is commonly an acceptable minimum perfusion target in many adults and does not, by itself, indicate catheter-related limb ischemia. A pressure bag set to 300 mm Hg is standard to maintain arterial line patency and waveform accuracy.

Question 4

The nurse is providing care to a client following a Prostatectomy. Which of the following nursing diagnosis is the priority?

Accepted Answer

Answer reason: After prostatectomy, bleeding can be occult but rapid and significant due to the vascularity of the prostatic bed and can lead to hypovolemia and shock if not detected promptly. This diagnosis drives close monitoring of urine output/color (e.g., increasing hematuria/clots), vital signs, drainage, and early intervention to prevent deterioration. While pain control and teaching are important, they are not immediately life-preserving compared with preventing/identifying postoperative bleeding.

Question 5

When a client diagnosed with acute urinary retention is emergently catheterized, the nurse should initially assess for which priority manifestation that may occur as a result of the catheterization?

Accepted Answer

Answer reason: After emergent catheterization, the nurse should monitor for dizziness, pallor, diaphoresis, and a drop in systolic pressure, because these can quickly lead to syncope or shock if unrecognized. Infection is a common complication of catheter use but is not typically an immediate post-procedure manifestation compared with acute blood pressure changes. Dysuria is more consistent with urethral irritation and is uncomfortable but not as life-threatening as an acute hypotensive episode.

Question 6

The nurse is collecting data from a client in labor who just had an amniotomy performed. The fetal heart rate (FHR) is 92. Which of the following would be consistent with the findings?

Accepted Answer

Answer reason: Amniotomy can allow the cord to slip past the presenting part, especially if the fetal head is not well engaged, leading to a prolapse and abrupt FHR drop into the 90s. This scenario requires immediate recognition because prolonged compression can rapidly cause fetal hypoxia and acidemia. A fetal cardiac anomaly may cause baseline abnormalities but would not typically present as an acute change immediately following membrane rupture. Polyhydramnios is a risk factor for cord prolapse but is not the direct finding that best explains the new bradycardia.

Question 7

Which client is at highest risk for deep vein thrombosis (DVT)?

Accepted Answer

Answer reason: DVT risk rises with factors that promote venous stasis and hypercoagulability, including advanced age, obesity, and smoking-related vascular/endothelial injury. This client has multiple strong, cumulative risk factors, making thrombosis more likely than in the other scenarios. The pediatric post-tonsillectomy client is typically ambulatory quickly and lacks major venous-stasis risks. A UTI with hypertension or observation for possible MI does not inherently confer as high a baseline thrombotic risk as the combination of advanced age plus obesity plus long-term smoking.

Question 8

A nurse is caring for a group of clients who are being considered for treatment with a negative pressure wound treatment device. The nurse should discuss this order with the practitioner when the client has which condition?

Accepted Answer

Answer reason: Eschar indicates devitalized tissue that can harbor bacteria and block drainage, increasing risk of infection and delayed healing if NPWT is applied. The nurse should question the order and clarify whether debridement is needed first and whether there are other contraindications (e.g., untreated infection, exposed organs/vessels). In contrast, NPWT is commonly used to support healing in wounds like dehiscence or certain chronic ulcers when the wound bed is appropriately prepared and monitored.

Question 9

The nurse assesses a preoperative client. Which question should the nurse ask the client, to help determine the client's risk for developing malignant hyperthermia in the perioperative period?

Accepted Answer

Answer reason: " Malignant hyperthermia is a life-threatening hypermetabolic reaction to certain anesthetic agents and is strongly associated with inherited susceptibility. A personal or family history of adverse reactions during general anesthesia is the most clinically relevant screening clue in the preoperative assessment. Identifying this risk allows the team to avoid triggering agents (e.g., volatile anesthetics, succinylcholine) and prepare rapid treatment with dantrolene and supportive measures. Heat stroke history and “normal” temperature range do not predict this pharmacogenetic reaction, and frequent infections are unrelated to perioperative malignant hyperthermia risk.

Question 10

The intensive care nurse is caring for a client diagnosed with a closed head injury. Which data would warrant immediate intervention?

Accepted Answer

Answer reason: A rapid decline in level of consciousness after a head injury indicates worsening cerebral function and is a red flag for rising intracranial pressure, expanding hemorrhage, or impending herniation. Dropping from 13 to 7 reflects progression from mild/moderate impairment to severe coma, requiring immediate airway protection, urgent neurologic reassessment, and prompt escalation for emergent diagnostics/ICP management. In contrast, a headache can be expected after head trauma but is not as immediately life-threatening as a major GCS deterioration. Refusal to cough and deep-breathe is concerning for pulmonary complications, but it does not outrank an acute, severe neurologic decline in immediacy.

Question 11

The nurse performs a physical assessment on a client diagnosed with bulimia nervosa. Which finding warrants an immediate referral to the health care provider?

Accepted Answer

Answer reason: A suddenly very weak/near-inaudible voice in bulimia can signal significant laryngeal irritation/trauma or edema from recurrent vomiting, raising concern for impending airway compromise that requires urgent medical evaluation. Prioritization in bulimia focuses on life-threatening complications (airway/cardiac/electrolyte-related) rather than expected chronic findings. Parotid enlargement and dental erosion are common, non-emergent manifestations of purging and warrant treatment but not immediate referral. Papulopustular eruptions are nonspecific and are less directly linked to an acute, high-risk complication in this context.

Question 12

A client with diabetes mellitus has had a right below-knee amputation. Given the client's history of diabetes mellitus, which complication is the client at most risk for after surgery?

Accepted Answer

Answer reason: These factors weaken collagen deposition and decrease the tensile strength of healing tissue, making dehiscence a key concern after surgery. Edema of the residual limb is common after amputation but is expected and managed with elevation/compression rather than being the most diabetes-specific complication. Hemorrhage is a general surgical risk but is not disproportionately driven by diabetes compared with impaired healing and wound breakdown.

Question 13

A nurse working in the postpartum unit assesses a newborn for injuries following forceps delivery. Which finding would the nurse attribute to a forceps delivery?

Accepted Answer

Answer reason: This is a recognized complication specifically associated with instrument-assisted births and should prompt focused neurologic assessment and monitoring of feeding/eye closure. Caput succedaneum is scalp edema more related to pressure from the presenting part during labor (often with vacuum), not uniquely forceps-related. Acrocyanosis is a common normal transitional finding, and pectus excavatum is a congenital chest wall deformity unrelated to delivery method.

Question 14

High pressure alarm in ventilator indicate ...?

Accepted Answer

Answer reason: An obstructed tube (e.g., secretions, kinking, biting) is a classic cause because it increases resistance to airflow. Patient–ventilator dyssynchrony (“fighting the ventilator”), bronchospasm, or coughing can also raise pressures by increasing resistance and/or decreasing effective compliance during inspiration. Tube displacement, especially mainstem intubation or malposition leading to uneven ventilation, can increase required pressure to deliver the set volume and trigger a high-pressure alarm, making the combined option the best answer.

Question 15

The nurse is caring for a patient who underwent a right nephrectomy. While assessing the patient, the nurse should place priority on?

Accepted Answer

Answer reason: After a nephrectomy, the most immediate priority is early detection of decreased renal perfusion or failure of the remaining kidney, and urine output is the most sensitive bedside indicator of renal function. Tracking hourly output helps identify hypovolemia, obstruction, acute kidney injury, or bleeding-related shock before later signs appear. While blood pressure contributes to perfusion assessment, it can remain normal despite evolving renal hypoperfusion and does not directly quantify kidney function. Pain and temperature are important postoperative assessments, but they are less urgent than confirming adequate urinary output from the remaining kidney.

Question 16

A client with acute respiratory distress syndrome (ARDS) is receiving positive pressure mechanical ventilation with 15 cm H2O positive end-expiratory pressure (PEEP). The nurse should assess for which complication associated with PEEP?

Accepted Answer

Answer reason: This can cause barotrauma (e.g., pneumothorax, subcutaneous emphysema), so the nurse should monitor for sudden respiratory deterioration, new unilateral absent breath sounds, and increasing peak pressures. Decreased oxygen saturation is more commonly a sign of worsening gas exchange or new complications, but it is not the characteristic complication specifically attributable to PEEP. Hypertension is not expected; if anything, elevated intrathoracic pressure from PEEP can reduce venous return and contribute to hypotension and decreased cardiac output.

Question 17

Which of the following is a risk factor for the development of pressure ulcers?

Accepted Answer

Answer reason: Low serum albumin is a marker of poor nutritional status and reduced protein availability for tissue maintenance and repair. Malnutrition impairs collagen synthesis, decreases skin integrity, and increases susceptibility to ischemic injury from pressure, shear, and friction. This makes skin breakdown more likely and slows healing if injury occurs. In contrast, an elevated white blood cell count reflects infection/inflammation rather than a primary predisposing factor for pressure-injury formation.

Question 18

A client has undergone pericardiocentesis to treat cardiac tamponade. The nurse should monitor the client for which sign to determine whether the tamponade is recurring?

Accepted Answer

Answer reason: This manifests clinically as pulsus paradoxus, a classic and sensitive sign that tamponade physiology is present or returning after pericardiocentesis. A recurring tamponade would be expected to trend toward hypotension and narrowing pulse pressure rather than a rising blood pressure. Decreasing pulse is nonspecific and not a hallmark finding compared with the diagnostic value of pulsus paradoxus.

Question 19

A 54-year-old patient underwent a thoracotomy. A chest tube was placed to help drain the blood and fluid from the pleural space. The nurse expects the hourly drainage to be less than?

Accepted Answer

Answer reason: After thoracotomy, expected chest tube output should trend down and remain below thresholds that suggest active hemorrhage. Persistent drainage above about 200 mL per hour is concerning for ongoing bleeding and warrants prompt surgical/team notification and closer hemodynamic assessment. This cutoff helps the nurse distinguish expected postoperative serosanguineous output from a complication requiring escalation. Higher values like 400 mL/hr would be abnormal in most postoperative contexts, whereas much lower cutoffs (e.g., 50–100 mL/hr) can still be within normal early postoperative drainage depending on time since surgery.

Question 20

A nurse cares for a client with an epidural catheter for labor pain management and requests additional medication. A student registered nurse anesthetist (SRNA) responds and administers medication via the epidural catheter. Which action performed by the SRNA requires the nurse to stop administration of medication?

Accepted Answer

Answer reason: Blood return on aspiration from an epidural catheter suggests inadvertent intravascular placement or migration, which creates a high risk for local anesthetic systemic toxicity if medication is injected. The safest action is to stop the dose and treat the catheter as malpositioned until the provider evaluates it. A negative aspiration is expected prior to dosing and supports (but does not guarantee) correct placement. Port cleansing and blood pressure assessment are appropriate safety steps and do not, by themselves, indicate a need to stop administration.

Question 21

The nurse is caring for a client with an inflammatory bowel disease exacerbation. The client is taking prescribed sulfasalazine. Which finding would require a priority follow-up by the nurse?

Accepted Answer

Answer reason: Urine specific gravity is 1.034 IBD exacerbations with frequent diarrhea create a high risk for dehydration and hypovolemia, which can rapidly progress to acute kidney injury if not addressed. A urine specific gravity of 1.034 indicates markedly concentrated urine and strongly supports significant fluid volume deficit requiring prompt assessment and intervention (vital signs, orthostasis, intake/output, labs, and likely fluid replacement). Yellow-orange urine can be an expected benign effect with sulfasalazine and is not urgent by itself. A mildly elevated WBC and ongoing bloody stools may be consistent with an active flare, but the immediate physiologic threat and most actionable priority cue here is dehydration risk suggested by the high specific gravity.

Question 22

A circulating nurse is orienting a nurse that is new to the operating room. What is the most important thing for the circulating nurse to teach to prevent the development of pressure sores during a six-hour surgery?

Accepted Answer

Answer reason: Prolonged immobility during surgery creates sustained pressure over bony areas, reducing tissue perfusion and leading to ischemic skin injury. In the OR, the primary prevention strategy is proactive positioning with padding before incision because the patient cannot be turned or exercised safely once sterile fields and anesthesia are established. This directly reduces focal pressure and shear at high-risk sites (sacrum, heels, elbows, occiput). Turning every two hours and performing ROM are standard on inpatient units but are generally not feasible during an ongoing procedure and can disrupt surgical access and safety. An alternating pressure mattress is less reliable/available intraoperatively and does not replace correct padding and positioning as the essential first-line measure.

Question 23

The nurse is giving an in-service on complications of positive pressure ventilation. Which should be included as a potential cause of alveolar hypoventilation?

Accepted Answer

Answer reason: Alveolar hypoventilation occurs when effective alveolar ventilation is inadequate, leading to CO2 retention, and on a ventilator this commonly results from loss of delivered tidal volume. A leak around the endotracheal tube cuff allows part of the set volume/pressure to escape, decreasing the amount of gas that actually reaches the alveoli and reducing minute ventilation. Excessive secretions more classically cause ventilation-perfusion mismatch and impaired oxygenation, and they may increase airway resistance, but the key mechanism tested for hypoventilation is insufficient effective delivered ventilation. High tidal volume would tend to increase alveolar ventilation (while risking barotrauma/volutrauma), and an incorrect respiratory rate could cause hypo- or hyperventilation, but the most direct complication-related cause listed is circuit/ETT air leak.

Question 24

The nurse is caring for a patient with suspected bowel perforation. Which of the following would be contraindicated for this patient?

Accepted Answer

Answer reason:  Suspected bowel perforation raises concern for peritonitis and worsening leakage of intestinal contents, so stimulating bowel motility or giving cathartics is unsafe. A saline/osmotic laxative can increase intraluminal pressure and peristalsis, potentially aggravating the perforation and spreading contamination. Diagnostic imaging such as abdominal CT is commonly used to evaluate for free air/contrast leak, and water-soluble contrast studies can be used when perforation is a concern. Definitive management may require urgent surgical exploration, so that intervention is not contraindicated when clinically indicated.

Question 25

A client is brought to the emergency department following a motor vehicle accident. Which observation of the client most concerns the nurse?

Accepted Answer

Answer reason: The priority after trauma is identifying actual or impending shock and life-threatening bleeding using ABCs and hemodynamic stability. Hypotension with tachycardia is an early, high-risk sign of hypovolemia/hemorrhagic shock (including occult internal bleeding) and demands immediate assessment and intervention. Abdominal pain/nausea and abdominal abrasions can indicate injury but are less urgent than abnormal vital signs signaling compromised perfusion. A staggering gait may reflect head injury or intoxication, but without airway compromise, active bleeding indicators, or unstable vitals it is not as immediately concerning as shock physiology.

Question 26

A client comes to the employee health nurse reporting an insect bite. The client was bitten while cleaning out the home basement. Which observation most concerns the employee health nurse?

Accepted Answer

Answer reason: This pattern suggests a clinically significant envenomation with evolving tissue ischemia/necrosis rather than a simple local inflammatory reaction. A bluish central area with surrounding mottling is concerning for a necrotic lesion (classically described with certain spider bites, including brown recluse), which can პროგресс to ulceration and systemic toxicity. In contrast, itching, erythema, mild burning, and limited swelling are common benign local responses to many insect bites. This finding warrants prompt medical evaluation, monitoring for systemic symptoms, and risk-reduction counseling to prevent worsening complications.

Question 27

The nurse is providing interventions to a patient with a deep vein thrombosis (DVT). Which of the following interventions should be avoided?

Accepted Answer

Answer reason: The key principle in acute DVT care is to prevent thrombus dislodgement and pulmonary embolism while supporting venous return and symptom control. Frequent ambulation can increase venous flow and mechanical movement in the affected extremity, which may mobilize an unstable clot before therapeutic anticoagulation is established. Elevation reduces edema and improves venous return, and analgesics address pain without increasing embolic risk. Local heat may be used to relieve discomfort and promote circulation as ordered, but the unsafe choice among these is encouraging frequent ambulation in the acute phase.

Question 28

The charge nurse should intervene if the new graduate nurse performs which action when caring for a jaundiced newborn being treated with phototherapy?

Accepted Answer

Answer reason: Clothing blocks light penetration and reduces the effective body-surface-area exposure, making therapy less effective and prolonging hyperbilirubinemia. Standard care is to keep the infant undressed except for a diaper while ensuring eye protection and thermoregulation. Feeding breaks are appropriate to support hydration and bilirubin elimination, and shielding the eyes is a required safety measure.

Question 29

An elderly patient had surgery two days for an intestinal obstruction. Vital signs at 10 am are temperature 37.5 C (99.5 f), heart rate 86, respiratory rate 16 blood pressure level 132/72 mm Hg, pain level 4 on a scale of 0 to 10. The abdominal dressing is dry and intact. The nasal gastric tube to low intermittent suction. The patient is on strict input and output every two hours. At 12.20 pm, the patient complains abdominal pain, upon assessment the vital signs are temperature 37.5 C, heart rate 98, respiration rate 24, blood pressure level 146/ 88 mm Hg, pain level is 8 out of 10. The patient abdomen is distended and rigid, the dressing remains dry and intact. The nurse should first?

Accepted Answer

Answer reason: With an NG tube on low intermittent suction, loss of patency can quickly lead to gastric distention, increased intra-abdominal pressure, tachypnea, and escalating pain. Checking patency by irrigating per protocol directly evaluates whether the tube is functioning and can rapidly relieve distention if it is obstructed. Giving analgesia first risks masking worsening abdominal findings and delaying recognition/management of a developing complication. Increasing suction intensity is not the first step because suction settings should be adjusted only after confirming the tube is correctly placed and patent.

Question 30

A client who is 2 hours post aortic valve replacement is in the intensive care unit (ICU). The low pressure alarm for the client's radial arterial line sounds. Which action should the nurse take first?

Accepted Answer

Answer reason: In a fresh post–cardiac surgery patient, the immediate priority is to assess for an actual complication that threatens circulation and safety before troubleshooting calibration. Inspecting tubing/connection sites quickly identifies active bleeding or a loose connection that must be corrected urgently. Re-leveling, zeroing, or fast-flushing are appropriate waveform/accuracy interventions, but they come after ruling out hemorrhage and system integrity issues.

Question 31

A nurse in the surgical admitting unit is preparing a client for elective coronary artery bypass surgery. Which statement by the client should the nurse report immediately to the health care provider (HCP)?

Accepted Answer

Answer reason: Antiplatelet therapy increases perioperative bleeding risk, and P2Y12 inhibitors like prasugrel are typically held several days prior to elective CABG to reduce risk of excessive surgical bleeding and transfusion. Taking the dose the morning of surgery may necessitate delaying the procedure or implementing alternative perioperative planning, so it requires immediate provider notification. In contrast, being NPO since the prior evening is expected pre-op preparation, pre-op anxiety can be addressed with reassurance/education, and difficult IV access is important to plan for but is not an immediate safety threat requiring HCP notification.

Question 32

The nurse is collecting data from a client who had percutaneous transluminal coronary angioplasty (PTCA) via the right femoral artery 2 hours ago. Which of the following findings would require immediate intervention?

Accepted Answer

Answer reason: A decreased dorsalis pedis pulse on the affected side is an early sign of impaired circulation that can rapidly progress to limb ischemia, requiring immediate assessment of color, temperature, capillary refill, sensation/movement and prompt provider notification. Small serosanguineous drainage and mild groin pain can be expected at the puncture site if not increasing and without hemodynamic instability. Nausea after water is nonspecific and not as time-critical as a neurovascular change indicating threatened limb perfusion.

Question 33

You are preparing to transfer Ms. N to the postpartum unit. Which statement by her would cause you to stop and reassess her before transfer?

Accepted Answer

Answer reason: A sudden “gushing” sensation after delivery is a red-flag for postpartum hemorrhage due to uterine atony or retained products, which requires immediate assessment and intervention before any transfer. This report suggests active heavy lochia with possible rapid blood loss, so the nurse should reassess uterine tone/fundal position, quantify bleeding, check vital signs, and initiate hemorrhage precautions as indicated. Sore nipples and uterine cramping are common postpartum findings related to breastfeeding and uterine involution and are not typically emergent. Dizziness with ambulation can signal hypovolemia, but “gushing” is more directly suggestive of acute significant bleeding and demands immediate action.

Question 34

In discharge teaching after cataract surgery, the client and family should be told to immediately report which symptom to the physician?

Accepted Answer

Answer reason: Analgesics should generally control expected discomfort; failure to respond suggests a complication requiring urgent evaluation. In contrast, mild scratchiness can be expected from corneal irritation or sutures, and altered depth perception with an eye patch is anticipated. Vision may be blurry initially after patch removal due to residual inflammation, dilation, or protective ointment, but unrelieved pain is the priority red flag.

Question 35

During report, the nurse is informed that a client's IV has 900 mL of fluid left in the bag. The nurse makes rounds 30 min later and notes the IV bag is empty. Which of the following is an appropriate nursing action?

Accepted Answer

Answer reason: A rapid, unintended infusion of a large IV volume creates immediate risk for circulatory overload and pulmonary edema, so the priority is to assess airway/breathing for early deterioration. New tachypnea, crackles, decreased oxygenation, or increased work of breathing would indicate fluid shifting into the lungs and require urgent intervention (slow/stop infusion per protocol, notify provider, possible diuretics/oxygen). This focused respiratory assessment is more sensitive and time-critical than a full vital sign set for detecting early fluid overload. Elevating the head of bed is supportive but should follow assessment, and NPO status does not address the acute complication risk.

Question 36

Upon arrival in the post-anesthesia care unit (PACU), the nurse performs the initial assessment of a client who had surgery under general anesthesia. Which assessment finding prompts the nurse to notify the health care provider (HCP) immediately?

Accepted Answer

Answer reason: This is a rapidly life-threatening complication due to uncontrolled skeletal muscle metabolism leading to acidosis, hyperkalemia, rhabdomyolysis, and cardiovascular collapse, requiring immediate provider notification and urgent treatment (e.g., dantrolene and active cooling/support). Being difficult to arouse can be expected soon after anesthesia and is first managed by airway/respiratory assessment and stimulation unless accompanied by respiratory compromise. Pinpoint pupils more strongly suggest opioid effect and can be assessed alongside respiratory rate/oxygenation, while mild hypothermia (96 F/35.6 C) is common post-op and is typically treated with warming measures rather than emergent notification.

Question 37

A client with a tracheostomy is alert and oriented and able to tolerate oral intake. Which action would be appropriate to reduce the client's risk of aspiration pneumonia?

Accepted Answer

Answer reason: An inflated tracheostomy cuff does not prevent aspiration and can worsen it by impairing laryngeal elevation and reducing effective cough and secretion clearance, promoting pooling above the cuff. Deflating the cuff allows more normal airflow through the upper airway and better swallow function when the patient is stable and able to eat, lowering the chance of aspirated material being retained and leading to pneumonia. Hyperextending the neck increases aspiration risk, and diet modification may be needed after a swallow evaluation but is not the key trach-specific action compared with cuff management.

Question 38

An obstetrical patient is in early labor and experiences rupture of membranes. The most important nursing priority is?

Accepted Answer

Answer reason: Rupture of membranes can be immediately complicated by umbilical cord prolapse or acute fetal compromise, making rapid evaluation of fetal status the first priority. The fastest, highest-yield nursing action is to assess the fetal heart rate to detect bradycardia or other nonreassuring patterns requiring urgent intervention. Notifying the provider is important, but it follows obtaining critical assessment data that may indicate an emergency and guide next steps. Epidural facilitation and urinary catheter insertion are non-urgent and do not address the time-sensitive risk to the fetus after membrane rupture.

Question 39

What is a nurse’s first priority when performing an assessment on a patient who underwent an esophagogastroduodenoscopy (EGD)?

Accepted Answer

Answer reason: After an EGD, sedation and topical anesthetic to the throat can suppress protective airway reflexes, creating a high aspiration risk. The immediate nursing priority is confirming gag reflex/ability to swallow before allowing anything by mouth. Providing ice chips or oral intake too early increases the chance of choking and aspiration. Pain control and discharge milestones like stool/flatus are secondary to airway protection and post-procedure safety.

Question 40

A patient is brought to the nursing unit after surgery for a mandibular fracture. When the patient complains of a runny nose, the nurse should first?

Accepted Answer

Answer reason: Clear nasal drainage after facial trauma/surgery can indicate cerebrospinal fluid leakage, which is an urgent potential complication requiring prompt assessment. Checking the fluid for glucose is a rapid bedside screen that helps differentiate CSF from ordinary nasal secretions. Identifying a possible CSF leak early supports immediate provider notification and measures to reduce meningitis risk. Comfort measures or empiric antihistamines could delay recognition of a serious postoperative complication.

Question 41

A nurse is rewarming a client after coronary artery bypass graft surgery. Which of the following complications can result from rewarming the client too quickly?

Accepted Answer

Answer reason: It also increases metabolic rate and catecholamine release, which can raise systemic vascular resistance and heart rate. Together these changes can precipitate hemodynamic instability, including elevations in blood pressure that stress fresh grafts and the myocardium. Infection and tissue necrosis are not direct acute consequences of rewarming rate, and acid–base shifts are more typically tied to perfusion/ventilation problems rather than the primary complication emphasized with overly rapid rewarming.

Question 42

A nurse cares for a client receiving total nutrient admixture (TNA). Which actions does the nurse perform while the client receives the infusion?

Accepted Answer

Answer reason: TNA/TPN solutions are highly concentrated in dextrose and can quickly cause hyperglycemia or hypoglycemia if infusion rates change or insulin coverage is inadequate. Ongoing blood glucose monitoring is a key nursing action to detect and manage this complication early and safely. Contacting the provider when the bag is complete is not the primary expected nursing action; instead, the nurse should anticipate timely replacement to avoid abrupt discontinuation and rebound hypoglycemia per facility protocol. Weekly weights are insufficient for TNA monitoring (weights are typically monitored more frequently), and IV tubing is not replaced each shift (it is changed per policy, often every 24 hours for TPN).

Question 43

The nurse and unlicensed assistive personnel (UAP) are performing rounds on their clients. The nurse notes that a 2-hour post vaginal delivery client has saturated the peripad with rubra drainage. What should the nurse do next?

Accepted Answer

Answer reason: The priority next step is rapid bedside assessment of uterine tone and position (fundus) to identify atony and guide immediate interventions such as fundal massage and evaluating for a full bladder. Delegating pad change delays assessment of a potentially life-threatening complication and does not address the cause. Ordering labs can be appropriate after initial assessment and stabilization, while increasing IV fluids is a nurse-driven intervention that should follow assessment and activation of hemorrhage management if indicated.

Question 44

A nurse in the intensive care unit (ICU) is caring for a client with sepsis who is on a mechanical ventilator (MV). The client is exposed to the noise of the MV, monitoring equipment, and infusion pump alarms during the day and night. What should the nurse identify as the priority nursing diagnosis (ND)?

Accepted Answer

Answer reason: g., accidental line/tube removal) and worsen outcomes. Sepsis, mechanical ventilation, sleep disruption, and continuous environmental noise are strong precipitants of acute confusion, so the nurse should prioritize identifying this risk and implementing prevention strategies (sleep promotion, reorientation, minimizing nighttime stimulation, early mobility as feasible). Disturbed sleep is important, but it is also a modifiable contributor to delirium rather than the most consequential diagnosis when combined with sepsis and ICU environmental triggers. Anxiety and powerlessness may be present, but they are less immediately linked to preventable physiologic complications than delirium risk in this context.

Question 45

A client's blood pressure is being monitored with an arterial catheter placed in the brachial artery. To prevent neurovascular complications while the catheter is in place, what action should the practical nurse (PN) implement?

Accepted Answer

Answer reason: Arterial lines can compromise distal perfusion via thrombosis, vasospasm, or catheter-related occlusion, creating risk for acute neurovascular impairment. Frequent neurovascular checks (distal pulses, color, temperature, capillary refill, sensation, and movement) are the key prevention strategy because they detect ischemia early when intervention can prevent tissue loss. Hourly assessment is appropriate for a brachial arterial catheter because this artery directly supplies the forearm/hand circulation. An Allen test is a pre-procedure assessment primarily used for radial artery cannulation rather than an ongoing measure for a brachial line.

Question 46

A child who had a cast applied to his arm earlier this morning tells the nurse that his fingers are numb. The nurse should?

Accepted Answer

Answer reason: The nurse’s immediate priority is to perform a focused neurovascular assessment of the distal extremity (e.g., color, temperature, capillary refill, pulses if applicable, movement, sensation) to determine severity and guide escalation. Interventions like cutting or bivalving the cast require an appropriate order/policy pathway and should follow assessment findings rather than precede them. Simply repositioning the arm may help edema but is not an adequate response before confirming distal perfusion and sensation are intact.

Question 47

The client with a postoperative left total knee replacement reports swelling, redness, warmth, and tenderness to the left calf. The nurse requests that the healthcare provider (HCP) prescribe which laboratory test?

Accepted Answer

Answer reason: D-dimer Postoperative unilateral calf swelling, warmth, erythema, and tenderness is concerning for a deep vein thrombosis, a potentially life-threatening complication due to risk of pulmonary embolism. D-dimer detects fibrin degradation products and is a useful initial lab to support the presence of acute thrombus when DVT is suspected. aPTT and INR primarily monitor anticoagulant therapy (heparin and warfarin, respectively) rather than help detect a new clot in an undiagnosed patient. Platelet count may be relevant for bleeding risk or heparin-induced thrombocytopenia but does not evaluate suspected venous thromboembolism itself.

Question 48

The nurse provides care to a client admitted to the emergency department (ED) after a motor vehicle crash (MVC). The health care provider (HCP) prescribes an MRI of the left eye after the client states, "I feel like there is something in my eye." Which response by the nurse is most appropriate?

Accepted Answer

Answer reason: " MRI safety requires screening for metallic foreign bodies, and suspected intraocular metal after trauma is a classic contraindication because the magnetic field can move the object and worsen ocular injury. The client’s report of a foreign-body sensation after an MVC raises concern for an embedded metallic fragment, so the nurse should question the order and advocate for an appropriate alternative (typically CT orbit) before transport. This response addresses prevention of a serious, avoidable complication rather than logistical preparation. The other responses focus on routine coordination/transport needs and do not mitigate the immediate MRI-related safety risk.

Question 49

A client is admitted to the hospital after experiencing a stroke or cerebral vascular accident (CVA). The nurse should request a referral for speech therapy if the client exhibits which finding?

Accepted Answer

Answer reason: Coughing during swallowing after a stroke is a classic sign of dysphagia with aspiration risk. Speech-language pathology evaluates swallowing function and recommends diet texture modifications, compensatory swallowing techniques, and communication therapy as indicated. Prompt referral helps prevent aspiration pneumonia, malnutrition, and dehydration by guiding safe oral intake. Findings like mood swings suggest emotional lability needing psychosocial/medical management, while facial droop or CN I/II deficits do not specifically indicate impaired swallow requiring speech therapy.

Question 50

The nurse is caring for a term newborn. Which assessment finding would predispose the newborn to the occurrence of jaundice?

Accepted Answer

Answer reason: A cephalhematoma is a localized collection of blood under the periosteum that breaks down over several days, increasing bilirubin load and raising the risk for hyperbilirubinemia. In contrast, blood type O negative by itself does not indicate hemolytic disease; ABO/Rh incompatibility risk depends on maternal–infant mismatch and antibody-mediated hemolysis. A negative direct Coombs’ test supports the absence of immune hemolysis, and a normal-to-large term birth weight is not a typical jaundice risk factor.

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