Question 1

Immediately following spinal anesthesia, what is the greatest risk?

Accepted Answer

Answer reason: Spinal anesthesia causes sympathetic blockade leading to vasodilation, decreased venous return, and drop in systemic vascular resistance; the immediate major risk is severe hypotension.

Question 2

The nurse is caring for a client who has altered cerebral tissue perfusion related to a subarachnoid hemorrhage. To reduce the risk of rebleeding, the nurse should plan to?

Accepted Answer

Answer reason: After subarachnoid hemorrhage, minimizing stimulation helps prevent increases in intracranial pressure and reduces risk of rebleeding. Restricting visitors promotes a quiet environment. Frequent arousal and hip flexion can increase ICP, and warming blankets are not indicated to prevent rebleeding.

Question 3

A 3 year-old child has tympanostomy tubes in place. The child's mother asks the nurse if he can swim in the family pool. The BEST response from the nurse is?

Accepted Answer

Answer reason: With tympanostomy tubes, water should be kept out of the ear canals to prevent infection; swimming is acceptable if ear plugs are worn.

Question 4

The nurse is caring for two children who have had surgical repair of congenital heart defects. For which one of the defects is it a PRIORITY to assess for signs of heart conduction disturbance?

Accepted Answer

Answer reason: Repair of a VSD involves the interventricular septum near the bundle of His and bundle branches; manipulation there increases risk of conduction block. Therefore monitoring for conduction disturbances is a priority after VSD repair.

Question 5

In teaching parents about the lifestyle of their child with sickle cell disease, the nurse should emphasize that their child should?

Accepted Answer

Answer reason: Overheating leads to fluid loss and dehydration, which can precipitate sickling and a vaso-occlusive crisis. Normal activity and routine immunizations are appropriate; addiction caution is not the key lifestyle teaching point.

Question 6

The nurse is caring for a seven year-old child who is being discharged following a tonsillectomy. Which of the following instructions is appropriate for the nurse to teach the parents?

Accepted Answer

Answer reason: Post-tonsillectomy hemorrhage is the primary risk; persistent coughing can indicate bleeding and also increases pressure at the surgical site, so it should be reported. Returning to school in 4 days is too early, aspirin increases bleeding risk (and Reye's), and gargling can disrupt clots.

Question 7

The nurse is assessing a client with delayed wound healing. Which of the following risk factors is MOST important in this situation?

Accepted Answer

Answer reason: Chronic corticosteroid therapy suppresses inflammation and collagen synthesis, impairing tissue repair and causing delayed wound healing. A glucose of 120 is normal, prior MI and a high-carb diet are less directly linked.

Question 8

The nursing care plan for a toddler diagnosed with Kawasaki Disease (mucocutaneous lymph node syndrome) should be based on the high risk for development of?

Accepted Answer

Answer reason: Kawasaki disease is a medium-vessel vasculitis in children; the most serious complication is coronary artery involvement leading to aneurysms. Other options are not typical primary risks.

Question 9

The nurse is speaking to a group of parents and school teachers of children about care for children with rheumatic fever. It is a PRIORITY to emphasize that?

Accepted Answer

Answer reason: In rheumatic fever, CNS involvement can cause Sydenham chorea. Early signs include behavior changes and clumsiness; prompt reporting helps identify complications early.

Question 10

A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. Vital signs are: temperature, 100°F, pulse 100, and BP 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority nursing diagnosis?

Accepted Answer

Answer reason: Recent alcohol use with elevated vital signs indicates withdrawal, which carries seizure and injury risk; lorazepam is given to prevent withdrawal complications.

Question 11

A nurse is caring for a client who is 4 hr postoperative following a transurethral resection of the prostate (TURP). Which of the following is the priority finding for the nurse to report to the provider?

Accepted Answer

Answer reason: After TURP, urine should be pink and light; thick red urine indicates active bleeding/clot formation and is the priority to report. The other findings are expected or less urgent.

Question 12

A nurse is reinforcing teaching about exercise with a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?

Accepted Answer

Answer reason: For type 1 diabetes, the client should avoid exercise when urine ketones are present because activity can worsen hyperglycemia and precipitate DKA. Carrying fast-acting simple carbohydrates (not complex) is recommended, exercising before breakfast increases hypoglycemia risk, and while avoiding injections into the exercising limb is reasonable, the key safety understanding is to hold exercise with ketonuria.

Question 13

The nurse is assessing a 55 year-old female client who is scheduled for abdominal surgery. Which of the following information would indicate that the client is at risk for thrombus formation in the post-operative period?

Accepted Answer

Answer reason: Estrogen therapy increases blood hypercoagulability, raising postoperative risk for venous thromboembolism. The other options do not increase clot risk.

Question 14

The nurse is planning care for a 3-month-old infant immediately postoperative following placement of a ventriculoperitoneal shunt for hydrocephalus. The nurse needs to?

Accepted Answer

Answer reason: Immediate post-op VP shunt care focuses on detecting complications of distal catheter in the peritoneum; abdominal distention may signal peritonitis or postoperative ileus. Infant should not be kept upright initially, feeds are delayed until bowel function returns, and shunt pumping is not a nursing action.

Question 15

The nurse is caring for a four year-old two hours after tonsillectomy and adenoidectomy. Which of the following assessments must be reported IMMEDIATELY?

Accepted Answer

Answer reason: Restlessness is an early sign of postoperative hemorrhage after tonsillectomy. Throat pain and dark emesis (swallowed blood) are expected findings, and a heart rate of 110 can be normal for a 4-year-old. Therefore restlessness requires immediate reporting.

Question 16

A client has returned to the unit following a renal biopsy. Which of the following nursing interventions is appropriate?

Accepted Answer

Answer reason: Post–renal biopsy the major risk is bleeding; frequent vital sign monitoring detects early signs of hemorrhage. The other options are not standard immediate post-biopsy care.

Question 17

The nurse is caring for a client with a distal tibia fracture. The client has had a closed reduction and application of a toe to groin cast. Thirty-six hours after surgery, the client suddenly becomes confused, short of breath and spikes a temperature of 103 degrees F. The FIRST assessment the nurse should perform is?

Accepted Answer

Answer reason: Post-op long-bone fracture with acute confusion, dyspnea, and fever suggests fat embolism causing hypoxemia. Priority is to assess oxygenation status; pulse oximetry provides immediate evaluation. Orientation, cast circulation, or blood pressure are secondary.

Question 18

A nurse is caring for a male client with a diagnosis of chronic gastritis and monitors the client knowing that this client is at risk for which vitamin deficiency?

Accepted Answer

Answer reason: Chronic gastritis leads to parietal cell atrophy and decreased intrinsic factor, impairing absorption of vitamin B12 and causing risk for pernicious anemia.

Question 19

A nurse is caring for a patient who had a percutaneous coronary intervention (PCI) with stent replacement. Which assessment finding should be reported immediately?

Accepted Answer

Answer reason: Post-PCI chest pain with dyspnea suggests acute complications such as acute stent thrombosis/restenosis and myocardial ischemia or infarction, which require immediate provider notification and rapid intervention. Mild pain at the catheter insertion site is expected postprocedure. A urine output of 40 mL/hr is adequate and capillary refill less than 3 seconds is normal. Therefore, the emergent finding is chest pain and shortness of breath.

Question 20

A nurse is caring for a post-operative patient and notices one of the previously sutured incision sites has started to open. The nurse uses which word to document her finding?

Accepted Answer

Answer reason: A previously sutured incision that has started to open is documented as wound dehiscence, meaning separation of the wound edges. Evisceration is a more severe complication where abdominal organs protrude through the opened incision. "Disruption" is nonspecific and not the standard clinical term for this postoperative complication. "Emulsification" is unrelated to surgical wound healing.

Question 21

A patient with a urinary catheter complains of lower abdominal pain. What is the most likely cause of the pain?

Accepted Answer

Answer reason: In a patient with an indwelling urinary catheter, lower abdominal (suprapubic) pain most commonly suggests bladder distention from inadequate drainage, such as catheter blockage, kinking, dependent loops, or an overfull drainage bag. Urinary retention leads to increased intravesical pressure and discomfort that improves after restoring urine flow (e.g., checking patency and irrigating per protocol). A UTI more often causes dysuria, fever, and cloudy/foul urine rather than acute suprapubic distention pain. Bladder perforation is rare and would usually present with severe pain, hematuria, and signs of peritonitis or shock; dehydration is not a typical direct cause of suprapubic pain with a catheter.

Question 22

A nurse is preparing to insert a nasogastric (NG) tube in a client. Which assessments should the nurse perform before inserting the tube?

Accepted Answer

Answer reason: This question most closely refers to preparation for nasogastric/nasotracheal insertion, where airway protection and ability to pass the tube safely are key. Checking nostril patency helps select the more open naris and reduces trauma/obstruction during insertion. Assessing an intact swallowing (and gag) reflex helps ensure the client can cooperate with swallowing to guide the tube into the esophagus and reduces the risk of misplacement/aspiration. The other options (blood sugar, urine output, pulse only) are not standard pre-insertion safety checks for this procedure.

Question 23

A nurse is monitoring a client on magnesium sulfate for neuroprotection. What sign may indicate magnesium toxicity?

Accepted Answer

Answer reason: Magnesium sulfate toxicity depresses the central nervous system and neuromuscular transmission, making diminished or absent deep tendon reflexes an early, classic warning sign. As serum magnesium rises further, respiratory depression, hypotension, and cardiac conduction abnormalities can occur. Nausea, headache, and blurred vision are nonspecific and are not as strongly associated with magnesium toxicity as loss of reflexes.

Question 24

Which symptom in a child with a VP shunt requires immediate medical attention?

Accepted Answer

Answer reason: The sunset eye sign (downward deviation of the eyes with prominent sclera above the iris) is a classic indicator of increased intracranial pressure, which can occur with VP shunt malfunction or obstruction. This is an urgent complication because rising intracranial pressure can rapidly lead to neurologic deterioration and herniation if not treated. Mild irritability, decreased appetite, or mild fever can be nonspecific and may occur with minor illness, but the sunset eye sign is a more specific red flag for shunt failure/raised ICP requiring immediate evaluation.

Question 25

The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider?

Accepted Answer

Answer reason: Separation of wound edges (dehiscence) on postoperative day 3 is an urgent complication because it can rapidly progress to evisceration and infection and requires prompt provider evaluation. A fever of 101°F and increased incisional pain can indicate infection, but wound edge separation is a more immediate structural failure with higher acute risk. A blood glucose of 136 mg/dL is mildly elevated and is not the most critical finding compared with evidence of wound dehiscence.

Question 26

A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which oxygen delivery system is most appropriate for this client?

Accepted Answer

Answer reason: For clients with COPD, controlled oxygen delivery is important to avoid excessive FiO2 that can worsen CO2 retention and respiratory acidosis. A Venturi mask delivers a precise, fixed FiO2 (e.g., 24–28%) and allows accurate titration to a target SpO2 (often 88–92% per provider order/policy). A non-rebreather provides very high FiO2 and is typically reserved for acute, severe hypoxemia. Nasal cannula and simple face masks provide variable FiO2 and are less reliable when precise control is needed.

Question 27

A client has undergone surgery for retinal detachment. Which of the following goal should be prioritized?

Accepted Answer

Answer reason: After retinal detachment surgery, the priority goal is to prevent increased intraocular pressure (IOP), because elevated IOP can disrupt the retinal repair and increase the risk of hemorrhage or re-detachment. Nursing care focuses on preventing actions that raise IOP such as coughing, vomiting, straining, or bending at the waist, and ensuring proper positioning if a gas bubble or buckle is used. Pain control is important but is secondary to protecting the surgical outcome and preventing complications. A darkened room and low-sodium diet are not primary postoperative priorities for retinal detachment repair.

Question 28

A newborn with hydrocephalus has a ventriculoperitoneal (VP) shunt placed. Which position is most appropriate immediately postoperatively?

Accepted Answer

Answer reason: Immediately after VP shunt insertion, the infant is typically kept supine with the head flat to avoid rapid CSF drainage, which can cause intracranial hypotension and increase risk of complications such as subdural hematoma. Elevating the head (e.g., Fowler’s or HOB 30°) can promote overdrainage early in the postoperative period. Side-lying or prone positions are less appropriate immediately because they may increase pressure on the operative site and are not standard for initial shunt stabilization and monitoring.

Question 29

The nurse is caring for a patient with a new order for an oral laxative. Which is a contraindication to administering an oral laxative?

Accepted Answer

Answer reason: Oral laxatives are contraindicated when abdominal pain is of unknown origin because they can worsen or mask an acute abdomen (e.g., bowel obstruction, appendicitis) and increase the risk of perforation or delayed diagnosis.

Question 30

A 7-year-old is 2 hours post-tonsillectomy with a temp of 38.1°C and throat pain. Priority action (left side) and complication (right side)?

Accepted Answer

Answer reason: In the first 24 hours after tonsillectomy, the most serious and time-sensitive complication is hemorrhage. Nursing priority is to monitor closely for bleeding (e.g., frequent swallowing, clearing throat, vomiting blood, tachycardia) and intervene promptly because airway compromise and shock can develop quickly. Mild fever and throat pain are expected early post-op and are lower priority than detecting and responding to bleeding.

Question 31

You are caring for a patient with active upper GI bleeding; what is the appropriate diet for this client during the first 24 hours after admission?

Accepted Answer

Answer reason: With active upper GI bleeding, the priority in the first 24 hours is to minimize gastric stimulation and reduce risk of worsening hemorrhage or vomiting/aspiration while diagnostic and therapeutic interventions (e.g., endoscopy) are planned. Keeping the patient NPO supports hemodynamic stabilization and allows timely procedures without aspiration risk. Clear liquids, milk, or a regular diet can stimulate gastric acid secretion and may aggravate bleeding or interfere with urgent evaluation.

Question 32

The nurse is caring for a client scheduled for removal of a pituitary tumor using the transsphenoidal approach. The nurse should be particularly alert for?

Accepted Answer

Answer reason: With a transsphenoidal pituitary surgery, the operative route is through the nasal cavity/sphenoid sinus, so nasal problems (congestion, drainage, bleeding) are common and can also signal complications such as obstruction or CSF leak. The nurse closely monitors nasal patency and drainage characteristics and avoids actions that increase nasal pressure (e.g., vigorous coughing/blowing). Abdominal tenderness is unrelated to the surgical approach, muscle tetany is not a typical targeted complication of this procedure, and oliguria is nonspecific and less directly linked than nasal findings.

Question 33

A patient is in labor and has just been told she has a breech presentation. The nurse should be particularly alert for which of the following?

Accepted Answer

Answer reason: Breech presentation is associated with a higher risk of umbilical cord prolapse because the presenting part may not adequately fill the pelvic inlet, allowing the cord to slip past after rupture of membranes. Cord prolapse can rapidly compromise fetal oxygenation due to cord compression, making it an urgent obstetric emergency. The nurse should therefore closely monitor for signs of cord prolapse and fetal distress and be prepared for immediate intervention. The other options are not specific acute complications of breech presentation.

Question 34

A post-operative patient is taught deep breathing exercises by the nurse. This intervention is?

Accepted Answer

Answer reason: Teaching deep-breathing exercises after surgery is an independent nursing intervention because it falls within the nurse’s scope and does not require a provider’s order. This education helps prevent post-operative pulmonary complications such as atelectasis and promotes adequate ventilation. Dependent interventions require a prescription, and collaborative interventions require coordination with other disciplines. It is not diagnostic because it is an intervention, not an assessment test.

Question 35

SCENARIO: A patient who had a myocardial infarction 2 days ago is participating in Phase I of cardiac rehabilitation. Which of the following activities is CONTRAINDICATED for a patient to do during this phase of rehabilitation?

Accepted Answer

Answer reason: In Phase I (inpatient/early) cardiac rehabilitation 1–3 days post-MI, activity is limited to light self-care and short ambulation while avoiding maneuvers that significantly raise heart rate and blood pressure. Isometric exercise can cause a disproportionate increase in afterload and myocardial oxygen demand, increasing risk for ischemia, arrhythmias, or reinfarction. The other options reflect appropriate early activities and monitoring of exertion during basic ADLs.

Question 36

Which scale assesses pressure ulcer risk?

Accepted Answer

Answer reason: The Braden Scale is specifically designed to assess a patient’s risk for developing pressure ulcers by evaluating sensory perception, moisture, activity, mobility, nutrition, and friction/shear. In contrast, the Morse Fall Scale evaluates fall risk, the Glasgow Coma Scale measures level of consciousness, and APGAR assesses a newborn’s adaptation after birth. Therefore, Braden is the correct tool for pressure injury risk screening.

Question 37

Which assessment finding suggests compartment syndrome?

Accepted Answer

Answer reason: Compartment syndrome is a limb-threatening complication of increased pressure within a fascial compartment that reduces tissue perfusion. A late but highly concerning sign is diminished or absent distal pulses due to compromised arterial flow, alongside severe pain and paresthesias. Increased urine output is unrelated, swelling that resolves with elevation suggests simple edema rather than rising compartment pressure, and warm skin is not typical of ischemia (skin may become cool/pale with poor perfusion).

Question 38

The nurse is educating parents about long-term complications after TEF surgery. Which of the following is the most common complication?

Accepted Answer

Answer reason: After tracheoesophageal fistula (TEF) repair, the most common long-term complication is an anastomotic esophageal stricture due to postoperative scarring, which can cause progressive dysphagia and feeding difficulties. Many infants also have associated GERD, which further increases stricture risk and need for dilation. Intestinal obstruction and renal dysfunction are not typical common sequelae of TEF repair, and delayed speech development is not a primary expected surgical complication.

Question 39

A premature infant is receiving oxygen therapy in the neonatal intensive care unit (NICU). Which complication is the nurse most concerned about?

Accepted Answer

Answer reason: Premature infants exposed to supplemental oxygen are at risk for retinopathy of prematurity due to oxygen-related disruption of normal retinal vascular growth, which can lead to scarring and retinal detachment. This is a key complication nurses monitor for by targeting ordered SpO2 ranges and ensuring appropriate oxygen delivery. Transient tachypnea is typically related to delayed lung fluid clearance, hyperbilirubinemia to immature hepatic conjugation, and PDA to persistent fetal circulation—none are as directly linked to oxygen toxicity as ROP.

Question 40

Postoperative care for a patient includes?

Accepted Answer

Answer reason: Deep breathing exercises are a key routine postoperative intervention to prevent atelectasis and reduce the risk of hypostatic pneumonia by improving lung expansion and secretion clearance. Prolonged bed rest for 48 hours is generally avoided because it increases risks of venous thromboembolism, atelectasis, and deconditioning. Routine fluid restriction is not standard unless specifically indicated (e.g., certain cardiac/renal issues). While early ambulation is beneficial, it is not typically “immediate” for all patients and depends on hemodynamic stability, anesthesia recovery, and procedure-specific orders; deep breathing is universally appropriate.

Question 41

Nurse Liza is assigned to care for a client who has returned to the nursing unit after left nephrectomy. Nurse Liza’s highest priority would be?

Accepted Answer

Answer reason: After a nephrectomy, the most immediate complication risk is inadequate renal perfusion or acute kidney injury in the remaining kidney, which is best detected early by closely monitoring urine output. Hourly urine output is a sensitive indicator of hemodynamic status, circulating volume, and kidney function in the immediate postoperative period. Temperature changes may indicate infection but is typically a later concern than renal function compromise. Turning and oral intake are important but are not as critical as ensuring adequate kidney function and perfusion right after surgery.

Question 42

The nurse suspects a postoperative anastomotic leak in a newborn following TEF repair. What symptom would confirm this suspicion?

Accepted Answer

Answer reason: After TEF repair, an anastomotic leak can allow air and secretions to escape into surrounding tissues, leading to respiratory compromise. Subcutaneous emphysema is a classic sign of air tracking into soft tissues and strongly suggests a leak. Associated coughing and respiratory distress reflect aspiration and/or pneumomediastinum/pneumothorax risk. Excessive oral secretions and drooling are more consistent with unrepaired TEF/esophageal atresia rather than a postoperative leak.

Question 43

Nurse Amber is caring for a client who underwent a lumbar laminectomy two (2) days ago. Which of the following findings should the nurse consider abnormal?

Accepted Answer

Answer reason: After lumbar laminectomy, new urinary retention or incontinence is abnormal because it can indicate neurologic compromise such as cauda equina syndrome or spinal nerve injury. This represents a potential postoperative complication requiring prompt assessment of motor/sensory function and provider notification. A low-grade temperature of 99.2°F is within expected postoperative variation, and localized paresthesia near the incision may occur from tissue/nerve irritation. Increased back pain on day 2 can occur with activity and postoperative inflammation, but new bladder dysfunction is a more concerning abnormal finding.

Question 44

Which of the following should be monitored during phototherapy?

Accepted Answer

Answer reason: During neonatal phototherapy, the nurse monitors temperature because infants can become hyperthermic or hypothermic due to increased insensible heat loss and exposure. Hydration status is critical because phototherapy increases insensible water loss and can contribute to dehydration, requiring monitoring of intake/output and daily weight. Bilirubin levels must be trended to evaluate treatment effectiveness and guide when to continue or discontinue therapy, making all listed parameters necessary to monitor.

Question 45

After cataract surgery, patient should avoid?

Accepted Answer

Answer reason: After cataract surgery, the priority is to prevent increased pressure or direct trauma to the operative eye that could disrupt the surgical site and increase risk of bleeding or wound dehiscence. Lying on the operated side can place external pressure on the eye (via pillow/bed contact) and may increase intraocular pressure. Semi-Fowler’s, sitting upright, and supine positioning (with head elevated as ordered) are generally acceptable and help reduce edema and discomfort. Therefore, the position to avoid is side-lying on the operated side.

Question 46

A newborn with tracheoesophageal fistula is scheduled for surgery. Which of the following preoperative interventions is essential?

Accepted Answer

Answer reason: In tracheoesophageal fistula, saliva and secretions can pool in the blind esophageal pouch and be aspirated into the airway, causing respiratory distress and pneumonia. The essential preoperative priority is maintaining a clear airway and reducing aspiration risk by continuously suctioning the proximal esophageal pouch (often with a Replogle tube) and keeping the infant NPO. Oral feeding (even thickened) increases aspiration risk, and Trendelenburg positioning can worsen reflux/aspiration. Pacifiers may provide non-nutritive comfort but do not address the critical airway/aspiration complication.

Question 47

The nurse is caring for a client eight hours following a total thyroidectomy. The nurse plans on obtaining an order to assess the client's serum?

Accepted Answer

Answer reason: After a total thyroidectomy, inadvertent removal or ischemia of the parathyroid glands can cause hypoparathyroidism, leading to hypocalcemia within the first 24–48 hours post-op (and sometimes earlier). Hypocalcemia can precipitate neuromuscular irritability and tetany (e.g., perioral numbness/tingling, cramps, Chvostek/Trousseau signs) and can progress to laryngospasm, which is a life-threatening airway complication. Monitoring serum calcium helps identify this complication early so calcium replacement can be initiated. Potassium, sodium, and glucose are not the priority labs specific to thyroidectomy complications.

Question 48

Which of the following is included in discharge teaching for parents of a baby who had TEF surgery?

Accepted Answer

Answer reason: After tracheoesophageal fistula (TEF) repair, infants remain at risk for complications such as anastomotic stricture or recurrent fistula that can cause dysphagia, choking, coughing with feeds, and aspiration. Aspiration can quickly progress to respiratory distress, so parents should be taught to monitor for feeding difficulty and breathing problems and seek prompt care. Sleeping completely flat increases reflux/aspiration risk, solids are not introduced at 3 months routinely, and prescribed pain medication may be needed and should not be universally avoided.

Question 49

A nurse is providing postoperative care for an infant who underwent surgical correction of TEF. What is the priority nursing intervention?

Accepted Answer

Answer reason: After tracheoesophageal fistula (TEF) repair, the highest priority is airway and breathing; infants are at risk for aspiration, respiratory compromise, and complications at the surgical connection (anastomotic leak). Close monitoring for respiratory distress and signs of leak (e.g., increased secretions, coughing/choking, fever, subcutaneous emphysema, worsening respiratory status) allows early intervention. Immediate oral feeding is not done until integrity of the repair is confirmed, and oral medications may be contraindicated initially; head-down positioning increases aspiration risk.

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