Question 1

A client with diverticulitis is admitted with nausea, vomiting, and dehydration. Which finding suggests a complication of diverticulitis?

Accepted Answer

Answer reason: A boardlike abdomen indicates peritoneal irritation from perforation, a serious complication of diverticulitis. LLQ pain and low-grade fever are typical of uncomplicated diverticulitis; distention is nonspecific.

Question 2

A client with otosclerosis is scheduled for a stapedectomy. Which finding suggests a complication involving the seventh cranial nerve?

Accepted Answer

Answer reason: Injury to the facial (VII) nerve is a known complication of stapedectomy and may present with abnormal facial nerve function. Of the options, facial changes best indicate VII involvement; tongue movement is CN XII, and diminished hearing/fullness are ear symptoms not specific to CN VII.

Question 3

The nurse is caring for a client following the reimplantation of the thumb and index finger. Which finding should be reported to the physician immediately?

Accepted Answer

Answer reason: After digit reimplantation, signs of vascular compromise must be reported immediately. Cool, discolored digits indicate impaired perfusion/ischemia, which threatens graft viability. Low-grade fever, pain, or limited movement are expected postoperative findings and less urgent.

Question 4

A client with primary sclerosing cholangitis has received a liver transplant. The nurse should give priority to assessing the client for complications. Which findings are associated with an acute rejection of the new liver?

Accepted Answer

Answer reason: Acute liver graft rejection impairs bile excretion and hepatic synthetic function, producing jaundice and a prolonged PT/INR. Fever with foul bile suggests infection, clay-colored stools are nonspecific, and elevated uric acid/creatinine indicate renal issues, not liver rejection.

Question 5

What is the primary concern for a patient with a junctional rhythm?

Accepted Answer

Answer reason: Junctional rhythm originates in the AV junction, often with a slower rate and loss of effective atrial kick, which can reduce stroke volume and lead to decreased cardiac output. Stroke risk is more tied to atrial fibrillation; heart failure and hypoxia are potential downstream effects, not the primary immediate concern.

Question 6

Prerequisites of Vaginal Birth After Caesarean Section (VBAC) in Ethiopia?

Accepted Answer

Answer reason: Each listed criterion is a standard safety requirement for attempting VBAC: single prior low-transverse CS with singleton cephalic fetus and adequate pelvis, EFW

Question 7

Which patient is most susceptible for acquiring secondary stomatitis?

Accepted Answer

Answer reason: Secondary stomatitis commonly results from opportunistic infections (e.g., Candida) in immunocompromised patients; AIDS confers the greatest immunosuppression among the options, making this patient most susceptible.

Question 8

For a client with hepatic cirrhosis who has altered clotting mechanisms, which intervention would be most important?

Accepted Answer

Answer reason: Cirrhosis impairs synthesis of clotting factors, increasing bleeding risk. Applying firm pressure after injections directly prevents bleeding. The other options do not address immediate bleeding risk; antibiotics are unrelated, independence of mobility may increase risk of injury/bleeding, and nutrition is a longer-term measure.

Question 9

The nurse is caring for the patient following removal of a large posterior oral lesion. The priority nursing measure would be to?

Accepted Answer

Answer reason: After posterior oral surgery, edema or bleeding can obstruct the airway. Using ABC priority, maintaining a patent airway is the immediate priority over oral care, dryness of incision, or pain assessment.

Question 10

The nurse is caring for the client with a mastectomy. Which action would be contraindicated?

Accepted Answer

Answer reason: After mastectomy, the affected arm should not be used for BP, venipuncture, or finger sticks to prevent lymphedema and impaired circulation. Elevating the affected arm and using the unaffected side are appropriate.

Question 11

The client is receiving peritoneal dialysis. If the dialysate returns cloudy, the nurse should?

Accepted Answer

Answer reason: Cloudy peritoneal effluent indicates possible peritonitis. The priority is to obtain and send a dialysate specimen for culture and analysis to confirm infection. Documentation alone delays care; straining urine is irrelevant; a CBC is secondary.

Question 12

The nurse is caring for a client scheduled for removal of the pituitary gland. The nurse should be particularly alert for?

Accepted Answer

Answer reason: Pituitary removal is commonly via a transsphenoidal (nasal) approach; nasal infection/URI increases postoperative complication risk (e.g., meningitis, CSF leak). Therefore the nurse should be alert for nasal congestion. The other findings are not expected: DI causes polyuria (not oliguria) and tetany relates to parathyroid, not pituitary; abdominal tenderness is unrelated.

Question 13

A client is admitted to the unit 2 hours after an injury with second-degree burns to the face, trunk, and head. The nurse would be most concerned with the client developing what?

Accepted Answer

Answer reason: Facial/head burns raise immediate risk for inhalation injury and rapid airway swelling. Within hours post-burn, laryngeal edema can obstruct the airway and is the highest-priority concern.

Question 14

The client is admitted following repair of a fractured tibia and cast application. Which nursing assessment should be reported to the doctor?

Accepted Answer

Answer reason: Paresthesia suggests neurovascular compromise/compartment syndrome after casting and requires immediate provider notification. Pain under a new cast can be expected, warm toes are normal, and the phrasing of weak and rapid pedal pulses is less specific; early nerve ischemia is best indicated by paresthesia.

Question 15

Which client is at risk for opportunistic diseases such as pneumocystis pneumonia?

Accepted Answer

Answer reason: Pneumocystis pneumonia is an opportunistic infection occurring primarily in immunocompromised clients. Chemotherapy causes significant immunosuppression (e.g., neutropenia), making these clients highest risk; the other conditions do not confer comparable opportunistic infection risk.

Question 16

A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is?

Accepted Answer

Answer reason: Post-tonsillectomy, highest priority is maintaining airway and preventing aspiration from blood and secretions while sedated; this risk outweighs pain or communication concerns.

Question 17

The client is having fetal heart rates of 100–110 beats per minute during the contractions. The first action the nurse should take is to?

Accepted Answer

Answer reason: FHR of 100–110 bpm during contractions suggests fetal compromise from uteroplacental insufficiency. The priority is to improve uterine perfusion and fetal oxygenation by turning the client to her side. Monitoring, ambulation, or moving to the delivery room do not address the immediate cause.

Question 18

The nurse is caring for a client with systemic lupus erythematosis (SLE). The major complication associated with systemic lupus erythematosis is?

Accepted Answer

Answer reason: Renal involvement (lupus nephritis) is the most significant complication of SLE and a major cause of morbidity and mortality. Cardiomegaly, desquamation, and meningitis are not typical primary complications.

Question 19

The nurse is caring for an infant following a cleft lip repair. While comforting the infant, the nurse should avoid?

Accepted Answer

Answer reason: After cleft lip repair, sucking actions can stress or disrupt the suture line. Pacifiers promote sucking and should be avoided; holding, a mobile, or small amounts of sterile water do not place tension on the repair.

Question 20

A client has rectal cancer and is scheduled for an abdominal perineal resection. What should be the priority nursing care during the post-op period?

Accepted Answer

Answer reason: The highest post-op risk is perineal wound infection or abscess; ensuring proper drainage prevents complications.

Question 21

The nurse assesses several post partum women in the clinic. Which of the following women is at HIGHEST risk for puerperal infection?

Accepted Answer

Answer reason: Postpartum infection is suggested by a maternal temperature of 100.4°F or higher on two successive days, excluding the first 24 hours after birth. Option C meets this criterion (100.8°F for the last 2 days at 3 days postpartum). Others do not.

Question 22

A client is admitted for COPD. Which of the following symptoms would require the nurse's IMMEDIATE attention?

Accepted Answer

Answer reason: Restlessness and confusion indicate hypoxemia and impending respiratory failure in COPD, requiring immediate assessment and intervention (e.g., ABGs, oxygen support).

Question 23

While caring for a client with infective endocarditis, the nurse must be alert for signs of pulmonary embolism. Which of the following assessment findings suggests this complication?

Accepted Answer

Answer reason: Pulmonary embolism commonly presents with acute dyspnea and cough (often with pleuritic chest pain). Homan's sign suggests DVT, fever and chills indicate infection, and sensory impairment is unrelated.

Question 24

The nurse observes a staff member caring for a client with a left unilateral mastectomy. The nurse would intervene if she notices the staff member is?

Accepted Answer

Answer reason: After mastectomy, avoid blood pressure, venipunctures, and injections on the affected arm to prevent lymphedema. Elevation and JP drain compression are appropriate; sodium restriction may reduce edema but is not harmful.

Question 25

A six month-old infant who is being treated for developmental dysplasia of the hip has been placed in a hip spica cast. The nurse should teach the parents?

Accepted Answer

Answer reason: Hip spica casts can impair circulation; parents should monitor distal neurovascular status. Swelling in the feet signals compromised perfusion. Inserting objects to scratch is unsafe, push–pull toys are not appropriate in the crib, and the abduction bar should not be used to turn the infant.

Question 26

A nurse caring for premature newborns in an intensive care setting carefully monitors oxygen concentration. The MOST important reason for this assessment is to prevent?

Accepted Answer

Answer reason: Excess oxygen in premature infants can cause retinal vaso-obliteration and neovascularization leading to retinopathy of prematurity; careful monitoring of oxygen concentration helps prevent this complication.

Question 27

While caring for a child with Reye's Syndrome, the nurse should give which of the following the HIGHEST priority?

Accepted Answer

Answer reason: Reye's syndrome can cause cerebral edema and increased intracranial pressure; the earliest and most critical indicator is a change in level of consciousness, making frequent neurological assessment the top priority.

Question 28

A client with chronic congestive heart failure should be instructed to contact the home health nurse if which of the following occurs?

Accepted Answer

Answer reason: Rapid weight gain signals acute fluid retention and worsening heart failure; patients are taught to report a gain of about 2–3 lb in 24–48 hours. The other options are not reliable indicators of decompensation.

Question 29

A hospitalized child suddenly has a seizure while his family is visiting. The nurse notes whole body rigidity followed by general jerking movements. The child vomits immediately after the seizure. A PRIORITY nursing diagnosis for the child is?

Accepted Answer

Answer reason: After a tonic–clonic seizure with vomiting, the immediate priority is airway protection; decreased consciousness increases the risk of aspiration.

Question 30

A two month-old infant has both a cleft lip and palate which will be repaired in stages. In the immediate postoperative period for a cleft lip repair, which one of the following nursing measures should be PRIORITY?

Accepted Answer

Answer reason: Immediate post-op care focuses on protecting the suture line. Elbow restraints prevent the infant from rubbing or traumatizing the repaired lip. Feeding resumption is not the top priority, alcohol should not be used on the incision, and positioning is helpful but secondary to protecting the operative site.

Question 31

A client is receiving oxygen therapy via a nasal cannula. When providing nursing care, which of the following interventions would be appropriate?

Accepted Answer

Answer reason: Oxygen via nasal cannula can dry mucosa and the tubing can exert pressure on nares and ears, risking skin breakdown; frequent inspection is appropriate. Adequate mist is not relevant to nasal cannula, lubrication of tips is not indicated and petroleum products increase fire risk, and sterile technique is unnecessary for a nasal cannula.

Question 32

A client was re-admitted to the hospital following a recent skull fracture. Which of the following symptoms requires the nurse's IMMEDIATE attention?

Accepted Answer

Answer reason: Lethargy indicates decreased level of consciousness, an early sign of rising intracranial pressure after head injury, and requires immediate intervention. Agitation, ataxia, or hearing loss are less emergent.

Question 33

The nurse is caring for a client on complete bed rest. Which action by the nurse is MOST important in preventing the formation of deep vein thrombosis?

Accepted Answer

Answer reason: Avoiding pressure in the popliteal area prevents compression of vessels, reduces venous stasis, and decreases the risk of DVT in bedrest patients.

Question 34

The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which of the following is an effective preventive measure?

Accepted Answer

Answer reason: Early mobility promotes venous return and reduces venous stasis, decreasing DVT risk. Pillows under knees can impede flow, continuous stockings require periodic removal/assessment and are not sufficient alone, and leg massage could dislodge a clot.

Question 35

The nurse is teaching parents about the treatment plan for a 2 week-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to IMMEDIATELY report?

Accepted Answer

Answer reason: Loss of consciousness signals severe hypoxia/anoxia in Tetralogy of Fallot and is an emergency requiring immediate medical attention; the other findings are concerning but not emergent.

Question 36

A client has just returned to the medical-surgical unit following a segmental lung resection. After assessing the client, the FIRST nursing action would be to?

Accepted Answer

Answer reason: Post-thoracic surgery clients often have copious secretions; maintaining a patent airway is the top priority. Suctioning addresses immediate airway patency before interventions like pain medication, TCDB, or monitoring.

Question 37

The nurse is caring for a client with acute pancreatitis. Which of the following, after pain management, should be included in the plan of care?

Accepted Answer

Answer reason: Acute pancreatitis can cause shallow respirations and risk of atelectasis/pneumonia from diaphragmatic irritation and pain. Encouraging coughing and deep breathing every two hours helps prevent pulmonary complications. Contact isolation and seizure precautions are not indicated, and during acute pancreatitis patients are usually NPO, not on high-protein diets.

Question 38

In providing care to acutely ill pediatric clients, the nurse should recognize that the child at HIGHEST risk for cardiac arrest is the individual experiencing?

Accepted Answer

Answer reason: In children, cardiac arrest most commonly follows respiratory failure; prolonged hypoxemia leads to bradycardia and subsequent arrest.

Question 39

The client returns to the recovery room following repair of an abdominal aneurysm. Which finding would require further investigation?

Accepted Answer

Answer reason: Post–abdominal aortic aneurysm repair, urine output should be at least 30 mL/hr. Output of 20 mL/hr suggests decreased renal perfusion or graft-related complications and warrants prompt investigation. The other findings are acceptable.

Question 40

Which sign suggests that a male client with syndrome of inappropriate antidiuretic hormone (SIADH) secretion is experiencing complications?

Accepted Answer

Answer reason: SIADH causes water retention and dilutional hyponatremia with decreased urine output. A complication is fluid volume excess, indicated by neck vein distension. Weight loss and polyuria are inconsistent with SIADH; tetany is related to hypocalcemia, not typical of SIADH.

Question 41

Which activity should the nurse encourage the client to avoid when there is a risk for increased intracranial pressure (ICP)?

Accepted Answer

Answer reason: Coughing increases intrathoracic pressure and can raise intracranial pressure, so it should be avoided. Deep breathing, turning, and passive ROM can be done carefully without significantly increasing ICP.

Question 42

A client undergoing long-term peritoneal dialysis at home is experiencing reduced outflow from the dialysis catheter; the nurse should inquire whether the client has which condition?

Accepted Answer

Answer reason: Constipation can displace or compress the peritoneal dialysis catheter and impede dialysate outflow; assessing and treating constipation restores flow.

Question 43

A client calls the nurse with a complaint of sudden deep throbbing leg pain. What is the appropriate FIRST action by the nurse?

Accepted Answer

Answer reason: Sudden deep throbbing leg pain suggests deep vein thrombosis. The priority is to prevent embolization by keeping the client on bed rest and notifying the provider; exercise or ambulation could dislodge the clot, and ice is not the first priority action.

Question 44

A nurse aide is taking care of a 2 year-old child with Wilm's tumor. The nurse aide asks the nurse why there is a sign above the bed that says DO NOT PALPATE THE ABDOMEN? The response by the nurse would be?

Accepted Answer

Answer reason: In Wilms tumor, palpating the abdomen can rupture the tumor capsule and seed malignant cells, so the abdomen should not be palpated.

Question 45

Immediately following insertion of a central line, the client develops tachycardia, cyanosis and hypotension. The nurse would IMMEDIATELY place the client in the?

Accepted Answer

Answer reason: Symptoms suggest an air embolism after central line insertion. Place the client in left lateral with head lowered (left-sided Trendelenburg) to trap air in the right atrium and prevent it from entering pulmonary circulation.

Question 46

The nurse is caring for an 87 year-old client with urinary retention. Which of the following should be reported immediately?

Accepted Answer

Answer reason: Fecal impaction can mechanically obstruct the bladder outlet and worsen urinary retention in the elderly, requiring prompt reporting and intervention. The other options are not immediate threats to bladder emptying.

Question 47

A client with multiple sclerosis plans to begin an exercise program. In addition to discussing the benefits of regular exercise, the nurse should caution the client to avoid activities which?

Accepted Answer

Answer reason: Heat and dehydration can exacerbate multiple sclerosis symptoms; clients should maintain hydration and avoid activities that could cause dehydration during exercise.

Question 48

The nurse is giving discharge teaching to a client 7 days post myocardial infarction. He asks the nurse why he must wait 6 weeks before having sexual intercourse. The nurse's BEST response to this question is?

Accepted Answer

Answer reason: After MI, resuming sexual activity is generally safe when the client can tolerate moderate exertion—often assessed by climbing two flights of stairs without symptoms—typically around 6 weeks as scar tissue forms.

Question 49

As a client is being discharged following resolution of a spontaneous pneumothorax, he tells the nurse that he is now going to Hawaii for a vacation. The nurse would warn him to avoid?

Accepted Answer

Answer reason: Scuba diving exposes the client to significant pressure changes that can precipitate another lung collapse after a spontaneous pneumothorax.

Question 50

The nurse is assessing a client who has had a spinal cord injury. Which of the following assessment findings would suggest the complication of autonomic dysreflexia?

Accepted Answer

Answer reason: Autonomic dysreflexia typically presents with acute severe hypertension and a pounding headache, often triggered by bladder or bowel irritation. It is associated with bradycardia, not tachycardia, and hypertension rather than hypotension. The bladder spasm is a trigger, not the hallmark assessment finding.

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