Question 1

An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in which best position at this time?

Accepted Answer

Answer reason: Side-lying is preferred rather than prone, because prone positioning can rub the face against bedding and contaminate the incision with secretions. With the repair on the right side, placing the infant on the left side keeps the operative site off the mattress and minimizes direct pressure on the suture line. Right lateral positioning would place the repaired area dependent and increases the chance of edema, bleeding, or disruption of the repair.

Question 2

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: This finding requires prompt nursing action: assess the site, reinforce/maintain a sterile dressing as indicated by protocol, keep the client in a position that minimizes leakage, and notify the provider. A moderate headache can occur after lumbar puncture and is often managed with hydration, analgesics, and positioning unless severe/progressive or with neurologic changes. Consuming fluids and being in a side-lying position are not inherently alarming compared with evidence of continuous drainage from the puncture site.

Question 3

The nurse is monitoring a client with chronic kidney disease (CKD). Which assessment finding should the nurse report to the health care provider?

Accepted Answer

Answer reason: New petechiae are an abnormal bleeding sign that may indicate worsening uremia or another coagulopathy and require prompt evaluation and possible treatment adjustments. In contrast, pallor and fatigue are common, expected findings related to anemia of chronic disease from reduced erythropoietin. Lethargy can occur with CKD, but petechiae more specifically signals a potentially urgent complication requiring provider notification.

Question 4

A client has been admitted to the medical surgical unit following an emergency cholecystectomy. There is a Jackson-Pratt drain with a portable suction unit attached. After 4 hours, the drainage unit is full. What should the nurse do?

Accepted Answer

Answer reason: A Jackson-Pratt drain must remain patent and compressed to maintain suction and prevent fluid accumulation that can increase infection risk and delay healing. When the bulb is full, suction is lost, so the immediate nursing action is to empty it using aseptic technique, measure the output, document amount/character, and then recompress and re-cap to reestablish suction. Notifying the surgeon is appropriate only if the volume or character is unexpected (e.g., sudden large sanguineous output) rather than simply because the bulb is full. Removing the drain is outside routine nursing scope without a provider order and could cause complications such as bleeding or bile leak.

Question 5

The client will have an abdominal hysterectomy tomorrow. Which information will be most important for the nurse to give to the client prior to admission to the hospital?

Accepted Answer

Answer reason: Clear NPO instructions (including when to stop solids, liquids, and certain medications) directly prevent a potentially life-threatening perioperative complication. Clothing choice and postoperative activity are important teaching points, but they do not carry the same immediate peri-anesthetic risk if misunderstood. Analgesic plan can usually be addressed after admission and is less critical than ensuring appropriate NPO status before surgery.

Question 6

The nurse is preparing to care for a client returning from the operating room after a subtotal thyroidectomy. The nurse anticipates the need for which of the following items to be placed at the bedside? 1 Hypothermia blanket 2 Emergency tracheostomy kit 3 Magnesium sulfate in a ready-to-inject vial 4 Ampule of saturated solution of potassium iodide (SSKI)?

Accepted Answer

Answer reason: Having an emergency tracheostomy kit at the bedside supports rapid airway access if the client cannot be ventilated adequately or develops acute obstruction. The other items do not address the priority complication in the immediate post-op period: warming devices are not standard thyroidectomy-specific needs, magnesium sulfate is not an expected rescue medication, and SSKI is used preoperatively to reduce thyroid vascularity rather than for routine postoperative bedside emergencies. NCLEX planning focuses on anticipating and preparing for high-risk complications with readily available equipment.

Question 7

The nurse cares for a patient who is on TPN, total parenteral nutrition. When checking their blood glucose, the nurse gets a reading of 415 mg/dl, What action does the nurse take next?

Accepted Answer

Answer reason: Severe hyperglycemia is a common complication of TPN due to the high dextrose load, and a value of 415 mg/dL indicates a significant metabolic complication requiring prompt treatment adjustment. The nurse should anticipate an order to modify the TPN regimen and/or initiate or titrate an insulin protocol (e.g., sliding scale, IV insulin, or insulin added to the TPN) based on institutional policy and the patient’s overall status. Abruptly stopping or reducing the infusion independently can precipitate rebound hypoglycemia and disrupt nutrition therapy, and it is typically a provider-directed change. Giving insulin without an existing order is outside nursing scope in most settings, so notifying the provider (and following any standing hyperglycemia protocol if available) is the safest next step.

Question 8

A nurse receives a client who has just returned from a circular skin punch biopsy to confirm a diagnosis of skin cancer. The nurse should immediately observe the site for?

Accepted Answer

Answer reason: Immediate post-procedure nursing assessment prioritizes early detection of acute complications that can quickly threaten stability. A punch biopsy creates an open wound with potential disruption of small dermal vessels, making active oozing or hemorrhage the most time-sensitive issue to identify and control with pressure/dressing reinforcement. Infection is a later complication that typically develops hours to days after the procedure rather than immediately on return. Dehiscence is uncommon with a small circular biopsy and would usually be preceded by uncontrolled bleeding or poor wound integrity over time.

Question 9

Lumbar puncture was performed on a client for a myelogram. After the procedure, he complains of severe headache. The most appropriate nursing intervention is?

Accepted Answer

Answer reason: Nursing care focuses on measures that help restore CSF volume/pressure and reduce symptoms, including encouraging fluids (and commonly caffeine if ordered) and maintaining prescribed positioning. Increasing oral fluid intake supports hydration and can help the body replenish CSF, making it the best option provided. Antihypertensives do not treat the underlying cause and may worsen perfusion if hypotension is present. Local cooling at the puncture site does not address the intracranial mechanism responsible for the headache.

Question 10

A registered nurse is precepting a new graduate nurse on the orthopedic unit. Which action by the graduate nurse requires the registered nurse to intervene?

Accepted Answer

Answer reason: Keeping an above-the-knee residual limb elevated on pillows encourages hip flexion and can quickly lead to a flexion contracture, which is difficult to reverse. Early care instead emphasizes maintaining neutral alignment and incorporating prone positioning as ordered/tolerated rather than prolonged pillow elevation. The other actions are standard orthopedic precautions/interventions that reduce complications (hip dislocation prevention, traction alignment, and edema control after casting).

Question 11

The nurse is assessing the neurovascular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg is warm, and the nurse notes redness and edema. The pedal pulse is palpable and unchanged from admission. How should the nurse correctly interpret the client's neurovascular status?

Accepted Answer

Answer reason: Aortoiliac bypass aims to restore arterial perfusion, which is best reflected by a palpable, unchanged distal pedal pulse and a warm extremity. Redness and edema shortly after surgery more strongly suggest venous congestion/venous outflow compromise or postoperative dependent swelling rather than acute arterial occlusion. If arterial flow were failing, expected findings would include coolness, pallor, delayed capillary refill, and diminished/absent pulses. Because the arterial assessment remains reassuring while swelling and erythema are present, the most accurate interpretation is adequate arterial supply with emerging venous-related issues that warrant ongoing assessment and supportive management.

Question 12

A client has been admitted to the hospital with a fractured pelvis sustained in a motor vehicle crash. The nurse monitors for complications and should assess the client closely for which finding in the early posttrauma period?

Accepted Answer

Answer reason: Blood in the urine is an early, specific clue of urinary tract damage and may precede signs of infection or later complications. Pain is expected with a fracture and is not a distinguishing complication signal. Fever typically develops later with infection, and bradycardia is not a typical early indicator of pelvic-fracture complications compared with hemorrhage/urogenital injury findings.

Question 13

A child is admitted to the hospital after being seen in the emergency department with complaints of right lower quadrant abdominal pain, nausea and vomiting, fever, and chills. The physician suspects appendicitis. Which of the following assessment findings would the nurse immediately report to the physician?

Accepted Answer

Answer reason: Perforation can quickly progress to peritonitis and sepsis, requiring urgent reassessment and possible emergent surgical management. Ongoing or worsening pain is expected with inflammation and is important to monitor, but it is less specific for rupture than sudden pain relief. A declining oral temperature or refusing oral fluids may occur with illness/NPO status and dehydration risk, but they are not as immediately alarming for acute deterioration as possible perforation.

Question 14

The nurse is performing an assessment on a pregnant client in the last trimester with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis?

Accepted Answer

Answer reason: Mucosal bleeding, petechiae, and purpura are classic clinical clues of low platelets and consumptive coagulopathy, which are life-threatening maternal complications requiring urgent escalation of care. The other findings reflect normal pregnancy or benign physiologic changes rather than end-organ dysfunction. Recognizing bleeding manifestations is critical because they signal high risk for hemorrhage (including placental abruption and postpartum hemorrhage) and imminent maternal deterioration.

Question 15

A client who was admitted to the psychiatric unit in a manic state attacked another client. Seclusion has been ordered, and the nurse is assessing the client every 15 minutes. Which assessment should receive the highest priority?

Accepted Answer

Answer reason: Frequent monitoring of circulation and cardiopulmonary status provides the earliest objective indicators of deterioration requiring immediate intervention or discontinuation/adjustment of seclusion. While ongoing observation of agitation and behavior is important for safety and determining readiness to end seclusion, it is secondary to detecting life-threatening physiologic instability. Nutritional intake is relevant over a longer time frame and does not supersede immediate assessment for acute complications.

Question 16

On the day of surgery, a client with diabetes who takes insulin on a sliding scale is to have nothing by mouth and all medications withheld. The client’s 0600 glucose level is 300 mg/dL (16.7 mmol/L). What should the nurse do?

Accepted Answer

Answer reason: Marked hyperglycemia preoperatively increases risk for dehydration, electrolyte shifts, impaired wound healing, and infection, and it may warrant delaying surgery until better controlled. An NPO order with “all medications withheld” conflicts with the need for glycemic management, and a glucose of 300 mg/dL is beyond routine “give and go” nursing management when the perioperative plan is unclear. The safest action is to obtain provider-specific orders (e.g., correction insulin, IV fluids, additional monitoring, or anesthesia/surgery guidance) to prevent perioperative complications. Administering insulin purely by a routine sliding scale may be inappropriate without knowing the protocol for NPO status and the perioperative target range, while simply withholding meds leaves severe hyperglycemia untreated.

Question 17

A client recovers from a laryngectomy and is mechanically ventilated. Which action does the nurse take when caring for the client?

Accepted Answer

Answer reason: In a mechanically ventilated patient with a tracheostomy, ensuring an adequate cuff seal with a minimal leak is essential to deliver the set tidal volume and prevent loss of ventilation. It also reduces aspiration risk by limiting leakage of secretions around the cuff. Routine suctioning on a fixed schedule is inappropriate because it increases mucosal trauma and hypoxemia risk; suction should be based on assessment (e.g., visible secretions, coarse breath sounds, rising peak pressures). Starting oral intake is unsafe immediately post-laryngectomy due to high aspiration risk and need to confirm swallowing safety and airway protection.

Question 18

The nurse cares for an elderly man diagnosed with Alzheimer's disease. It is MOST important for the nurse to take which action?

Accepted Answer

Answer reason: Alzheimer’s disease commonly causes disorientation and impaired short-term memory, increasing the risk for wandering and falls. Frequent reorientation to essential locations supports safe ambulation and helps the client meet basic needs with less anxiety and confusion. This intervention addresses both safety and cognitive support in a direct, ongoing way. In contrast, leaving the television on all day can worsen agitation and overstimulation, and frequent checks alone do not correct disorientation or promote independent, safe navigation.

Question 19

A nurse suspects that an air embolism has occurred when the client's central venous catheter disconnects from the intravenous (IV) tubing. The nurse immediately places the client in which position?

Accepted Answer

Answer reason: Placing the client in left lateral decubitus with Trendelenburg (Durant maneuver) uses gravity to keep air in the apex of the right ventricle and away from the pulmonary outflow tract. This positioning also reduces the risk of hemodynamic collapse from obstruction of pulmonary blood flow. Reverse Trendelenburg would favor air migration toward the pulmonary artery and worsen the complication. Immediate positioning is a critical nursing action while further emergency measures are initiated.

Question 20

A patient is newly diagnosed with cirrhosis of the liver. Which of the following statements indicates he understands his condition?

Accepted Answer

Answer reason: Cirrhosis causes portal hypertension and low albumin, which commonly leads to ascites and abdominal fluid accumulation. Therapeutic paracentesis is an appropriate procedure to relieve significant ascites and respiratory discomfort and is a typical complication-management plan patients should understand. Digoxin is a cardiac medication and is not a standard treatment for cirrhosis itself. Cirrhosis is generally progressive/irreversible, and alcohol recommendations emphasize complete abstinence rather than limiting drinks to a few times per week.

Question 21

The hemodialysis client with a left arm fistula is at risk for steal syndrome. The nurse assesses this client for which of the following clinical manifestations?

Accepted Answer

Answer reason: Steal syndrome occurs when an AV fistula diverts arterial blood away from the distal extremity, producing distal ischemia. Ischemia is assessed by coolness/pallor, reduced or absent distal pulses, and pain (often worse during dialysis or with hand use) in the hand beyond the fistula. Findings like warmth and redness suggest infection or inflammation rather than decreased perfusion. Arm edema and reddish discoloration more strongly point to venous outflow obstruction or thrombosis rather than arterial “steal.”.

Question 22

The nurse is caring for a client with benign prostatic hyperplasia (BPH) who had an indwelling urethral catheter removed 6 hours ago. Which of the following findings by the nurse would be a priority to follow up?

Accepted Answer

Answer reason: A distended/palpable bladder combined with minimal output several hours after removal strongly suggests obstruction/retention, which is a time-sensitive complication in a client with BPH. This finding warrants immediate assessment (e.g., bladder scan) and prompt intervention per protocol to prevent worsening retention. In contrast, transient burning can be expected after catheter removal, and isolated BUN elevation or intake exceeding output is less immediately diagnostic of acute obstruction in this moment.

Question 23

A client scheduled for pneumonectomy tells the nurse that a friend of his had lung surgery and had chest tubes. The client asks the nurse about how long his chest tubes will be in place after surgery. The nurse responds that?

Accepted Answer

Answer reason: After a pneumonectomy, the operative hemithorax is intentionally left without a lung, so placing a standard chest tube to continuous suction can create excessive negative pressure and shift mediastinal structures, impairing hemodynamics and ventilation. Postoperative management typically aims to allow the space to fill gradually with fluid and for the mediastinum to stabilize. If any drainage device is used, it is generally temporary and specifically managed (e.g., clamped or without suction) rather than routine ongoing chest-tube therapy. Therefore the safest, most accurate expectation for patient teaching is that routine chest tubes are usually not present after pneumonectomy, unlike many other lung resections.

Question 24

A client undergoes a thyroidectomy and the nurse monitors the client for signs of damage to the parathyroid glands postoperatively. Which of the following findings would indicate damage to the parathyroid glands?

Accepted Answer

Answer reason: Early hypocalcemia commonly presents with perioral tingling/numbness and can progress to tetany (e.g., carpopedal spasm, positive Trousseau/Chvostek) and laryngospasm. This finding is therefore a key postoperative complication cue that specifically points to parathyroid dysfunction rather than expected incision discomfort. Hoarseness more strongly suggests recurrent laryngeal nerve irritation, and generalized respiratory distress is less specific without accompanying hypocalcemic neuromuscular signs.

Question 25

After a frontal craniotomy, a patient returns to the neurosurgery unit. Which of the following orders should the nurse question?

Accepted Answer

Answer reason: A rate of 160 mL/hr is relatively high for routine maintenance and should prompt clarification about the indication, fluid type, and targeted intake/output goals. Typical postoperative neuro care often uses controlled or restricted fluids with close monitoring of urine output, serum sodium/osmolality, and neurologic status. By contrast, head-of-bed elevation and low-flow oxygen support cerebral venous drainage and oxygenation, and corticosteroids may be ordered to reduce vasogenic edema depending on the pathology.

Question 26

The nurse is initiating continuous bladder irrigation on a patient that just underwent a prostatectomy. The nurse understands that the flow rate is adequate if?

Accepted Answer

Answer reason: An adequate rate produces effluent that is light pink to pale yellow, indicating small expected postoperative oozing without significant active hemorrhage. If the urine becomes bright red or contains increasing clots, the rate is too low or bleeding is increasing; if it is completely clear, the rate may be higher than needed. “Output equals input” is incorrect because true urine output must be calculated by subtracting irrigant infused from total drainage.

Question 27

The nurse is caring for a client with the syndrome of inappropriate antidiuretic hormone (SIADH). Which assessment finding requires immediate follow-up?

Accepted Answer

Answer reason: Acute or worsening neurologic changes signal cerebral edema and impending seizures, making this a time-sensitive complication that requires prompt evaluation and intervention. High urine specific gravity and oliguria are expected effects of ADH-mediated water reabsorption and are not, by themselves, the most urgent red flags. Increased thirst is less typical as a priority finding in SIADH and is not as immediately dangerous as altered mental status.

Question 28

The nurse is planning care for a child being admitted with Kawasaki disease and should give priority to which nursing intervention?

Accepted Answer

Answer reason: A gallop rhythm can indicate decreased ventricular function, and reduced urine output is an early sign of poor perfusion and evolving shock/heart failure. This option focuses on monitoring for life-threatening complications that require prompt escalation of care and treatment adjustments. Comfort measures, environmental rest, and diet/hydration support symptoms but do not supersede surveillance for cardiac deterioration.

Question 29

A nursing intervention in thrombophlebitis would be contraindicated?

Accepted Answer

Answer reason: Manipulating the limb can mechanically disturb the thrombus and increase the chance of a potentially fatal pulmonary embolus. Supportive measures such as heat can help reduce pain and promote local circulation without physically disrupting the clot. Bedrest and gentle repositioning are commonly used to limit venous stasis and prevent additional complications while anticoagulation and other therapies take effect.

Question 30

A client diagnosed with a sub-arachnoid hemorrhage has undergone a craniotomy for repair of a ruptured aneurysm. Which intervention will the intensive care nurse implement?

Accepted Answer

Answer reason: A stool softener reduces constipation and minimizes bearing down during defecation, directly lowering this risk. Hourly coughing can transiently increase ICP and is not routinely promoted aggressively in this context unless clearly indicated for airway clearance. Neurologic checks should be more frequent than once per shift in an ICU after craniotomy, and targeting hypertension with dopamine is inappropriate because dopamine typically raises blood pressure and may worsen bleeding risk.

Question 31

The nurse cares for a client who returns from the operating room after a tracheostomy tube placement procedure. Which of the following is the nurse's priority when caring for a client with a new tracheostomy?

Accepted Answer

Answer reason: Securing the tube with appropriately snug ties reduces this immediate, high-consequence complication while avoiding excessive pressure that can impair skin integrity and venous return. Early inner cannula changes and oral care are important but are secondary to maintaining a patent, secure airway device. Routine cuff deflation/reinflation is not a priority nursing action immediately post-op and can destabilize ventilation/aspiration protection if done without a specific indication and monitoring.

Question 32

A client has a chest-drainage tube after a thoracotomy was performed. The nurse should report which assessment finding to the surgeon immediately?

Accepted Answer

Answer reason: Increasing bloody output after initially scant drainage can indicate postoperative hemorrhage, disruption of a vessel, or loss of hemostasis and warrants urgent surgeon notification. By contrast, tidaling in the water-seal chamber reflects expected pleural pressure changes and is a normal finding when the system is patent. Immediate postoperative drainage can be sanguineous, and a single-hour volume must be interpreted with trends and hemodynamics; the pattern of rising bleeding is the more concerning signal for acute deterioration.

Question 33

The nurse caring for a client diagnosed with an inoperable lung tumor creates a plan of care addressing complications related to the disorder. The nurse includes in the plan to monitor for the early signs/symptoms of vena cava syndrome. Which is an early sign/symptom of this oncological emergency?

Accepted Answer

Answer reason: Early findings reflect venous congestion above the obstruction, classically facial/periorbital swelling and a feeling of head fullness that may be worse when bending forward or lying down. Upper-extremity edema can occur but facial/periorbital edema is a hallmark early cue nurses monitor for to detect progression quickly. Disorientation suggests later cerebral edema/hypoxia, and perioral cyanosis indicates more advanced respiratory compromise rather than an early sign of SVC obstruction.

Question 34

The nurse prepares to administer a continuous intravenous (IV) infusion through a peripheral IV to a client who has dehydration. Which is the priority nursing assessment before initiating the IV infusion?

Accepted Answer

Answer reason: Recent urine output and overall fluid balance provide the most immediate, actionable baseline for titrating a continuous infusion and identifying risk for complications (e.g., oliguria suggesting poor kidney perfusion). Daily weight is useful for trending but is less immediate for pre-infusion decision-making than fluid balance data. Serum electrolytes are important but may not be available immediately and do not directly indicate current circulating volume or urine production needed to guide starting fluids safely.

Question 35

While assessing a thoracotomy incisional area from which a chest tube exits, the nurse feels a crackling sensation under the fingertips along the entire incision. What should the nurse do next?

Accepted Answer

Answer reason: Crackling under the skin after thoracotomy with a chest tube is consistent with subcutaneous emphysema from air leaking into subcutaneous tissue. The immediate nursing priority is to assess and trend the extent by outlining the margins so progression or resolution can be evaluated objectively and communicated. This supports early recognition of worsening air leak or inadequate chest tube function while allowing targeted follow-up assessment. Calling the provider may be needed if it rapidly progresses or causes respiratory compromise, but the next action is to quantify and document the finding first.

Question 36

When preparing a client for discharge 2 days after an abdominal hysterectomy, the nurse should instruct the client to avoid which activity until recovery is complete?

Accepted Answer

Answer reason: Submerging in water (pool, bath, hot tub) increases exposure to microorganisms and moisture, which can promote wound or vaginal-cuff infection and delay healing, so it should be avoided until cleared—commonly around 6 weeks. Early ambulation is encouraged to reduce thromboembolic risk and support bowel function. Driving is typically allowed when the patient can safely perform an emergency stop and is not impaired by pain or sedating analgesics. Lifting restrictions are appropriate, but an absolute limit of >2 lb is unusually strict and less representative of standard discharge guidance than the clear “no submersion” precaution.

Question 37

The nurse is caring for a client diagnosed with acute pericarditis. Which complication is the client at risk for developing?

Accepted Answer

Answer reason: Acute pericarditis can lead to inflammatory pericardial effusion, and rapid fluid accumulation in the pericardial sac can compress the heart and impair ventricular filling. This reduces stroke volume and cardiac output and can quickly progress to obstructive shock, making it the key life-threatening complication to monitor for. The other options are primarily pleural/lung (hemothorax, tension pneumothorax) or thromboembolic (pulmonary embolism) processes and are not the characteristic direct complication of pericardial inflammation. Clinically, new hypotension, muffled heart sounds, rising JVP, or pulsus paradoxus would heighten concern for this complication and warrant urgent intervention.

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