Question 1

A 38-year-old woman is returned to her room after a subtotal thyroidectomy for treatment of hyperthyroidism. Which of the following, if found by the nurse at the patient's bedside, is nonessential?

Accepted Answer

Answer reason: After thyroidectomy, priority bedside preparedness focuses on airway and bleeding risks and on hypocalcemia from possible parathyroid injury. Therefore, suction equipment and a tracheostomy set-up are essential for potential airway compromise, and IV calcium gluconate is essential to treat acute symptomatic hypocalcemia/tetany. Potassium chloride is not routinely required as an emergency bedside item specific to post-thyroidectomy complications, making it the nonessential option.
Category reason: The question tests postoperative nursing preparedness for anticipated complications after thyroid surgery (airway compromise and hypocalcemia), which is a patient-safety risk-reduction focus rather than foundational science.

Question 2

A nurse is providing discharge teaching for a client who has an implantable cardioverter defibrillator which of the following statements demonstrates understanding of the teaching?

Accepted Answer

Answer reason: Loose clothing helps prevent irritation, pressure, or friction over the ICD incision and generator site, supporting healing and reducing risk of skin breakdown or discomfort. Soaking in a tub early after implantation is typically avoided because it can increase infection risk at the incision site; showering is usually allowed once cleared. Microwaves are generally safe with modern ICDs and do not require avoidance. Cell phones should be kept at least about 6 inches from the device and not carried/used on the same side to reduce electromagnetic interference risk.
Category reason: This item tests discharge teaching to prevent complications and reduce risks for a client with an implanted cardiac device, which aligns with monitoring/preventing potential complications under Reduction of Risk Potential.

Question 3

A patient with heart failure is receiving IV furosemide. The nurse notes a potassium level of 2.9 mEq/L. Which action should the nurse take first?

Accepted Answer

Answer reason: A potassium level of 2.9 mEq/L indicates significant hypokalemia, which increases the risk of life-threatening dysrhythmias, especially in a patient with heart failure receiving a loop diuretic. The priority is to detect and respond promptly to cardiac electrical instability by monitoring the cardiac rhythm (e.g., telemetry/ECG). Notifying the provider and administering potassium are important next steps, but they follow immediate assessment for imminent complications. Stopping furosemide may be considered depending on severity and orders, but continuous rhythm monitoring addresses the most immediate safety threat.
Category reason: This item tests nursing prioritization and prevention of complications from an abnormal lab value (hypokalemia) during therapy, which aligns with monitoring for complications in Reduction of Risk Potential.

Question 4

A nurse is caring for a client after a thyroidectomy. The client suddenly develops hoarseness and difficulty speaking. What is the nurse's priority action?

Accepted Answer

Answer reason: After thyroidectomy, sudden hoarseness and difficulty speaking can indicate laryngeal edema, hematoma, or recurrent laryngeal nerve involvement, all of which can rapidly compromise the airway. Airway assessment is the immediate priority because obstruction can progress quickly and become life-threatening. Documentation, voice rest, and reassurance may be appropriate later, but they do not address the urgent risk of airway compromise. The nurse should assess airway patency (e.g., stridor, respiratory distress) and be prepared to escalate care promptly.
Category reason: This is a postoperative nursing priority question focused on recognizing and responding to a potential complication (airway compromise) after thyroidectomy, which aligns with Reduction of Risk Potential—Potential for Complications.

Question 5

A client receiving parenteral nutrition (PN) in the home setting has a weight gain of 5 lb in 1 week. The nurse should next assess the client for the presence of which condition?

Accepted Answer

Answer reason: A 5-lb weight gain in one week while receiving parenteral nutrition suggests fluid retention and possible fluid volume excess from the hyperosmolar infusion and added free water. The priority assessment is for signs of pulmonary congestion/edema, such as crackles on lung auscultation, which can indicate worsening fluid overload. Thirst and polyuria are more consistent with hyperglycemia/dehydration, and decreased blood pressure would not align with fluid volume excess.
Category reason: This item tests nursing assessment for a complication of parenteral nutrition (fluid volume excess/pulmonary edema), which is a patient-care safety concern and fits Potential for Complications under Reduction of Risk Potential.

Question 6

A nurse is assessing a client with a fractured femur in skeletal traction. Which finding requires immediate attention?

Accepted Answer

Answer reason: Severe, unrelieved pain in a client with a fractured femur in skeletal traction can indicate a serious complication such as acute compartment syndrome or neurovascular compromise, which requires rapid assessment and intervention. Pain out of proportion to the injury and not relieved by analgesics is an early warning sign and should prompt immediate neurovascular checks and provider notification. Slight redness at the pin site and clear drainage can be expected early findings if there are no other signs of infection, and capillary refill

Question 7

A postpartum client delivered vaginally 1 hour ago. Fundus is firm at the umbilicus, but she saturates 2 pads in 30 minutes. What is the priority action?

Accepted Answer

Answer reason: Heavy bleeding (soaking 2 pads in 30 minutes) 1 hour postpartum is concerning for postpartum hemorrhage. A firm, midline fundus suggests uterine atony is less likely; persistent bleeding with a firm uterus points to genital tract trauma (lacerations) or concealed bleeding from a hematoma. The priority nursing action is to assess the perineum and vaginal area for lacerations/hematoma to identify the cause and guide urgent intervention. Fundal massage or increasing oxytocin primarily treats uterine atony, and notifying the provider should occur promptly after focused assessment identifies the likely source.
Category reason: This is a postpartum patient-care scenario requiring nursing assessment and prioritization to identify a potential complication (postpartum hemorrhage from laceration/hematoma), which aligns with NCLEX Reduction of Risk Potential—Potential for Complications.

Question 8

A client had a total thyroidectomy yesterday and complains of tingling around the mouth and fingers. What should the nurse do next?

Accepted Answer

Answer reason: Perioral and fingertip tingling after thyroidectomy is a classic early sign of hypocalcemia from inadvertent parathyroid injury or removal, which can progress to tetany, laryngospasm, and seizures. The priority nursing action is to assess for this complication by checking the calcium level (and monitoring for other signs such as Chvostek/Trousseau). While airway/emergency equipment may become necessary if symptoms worsen, confirming and trending calcium guides timely treatment with calcium supplementation. Dressing assessment and blood pressure are important postoperative checks but do not address the most likely cause of these neurologic symptoms.
Category reason: The question tests nursing recognition and immediate assessment of a postoperative complication (hypocalcemia) after thyroidectomy, which fits NCLEX Reduction of Risk Potential—Potential for Complications.

Question 9

Nurse is caring for a client with osteomyelitis. Which order should the nurse question?

Accepted Answer

Answer reason: Acute osteomyelitis requires limiting use of the affected bone to reduce pain, prevent worsening inflammation, and decrease risk of pathologic fracture. Frequent ambulation can increase stress on infected bone and promote spread of infection or delay healing. IV antibiotics and a high-protein diet support infection control and tissue repair. Elevation can help reduce swelling and discomfort in an affected extremity, whereas routine frequent ambulation should be questioned unless specifically cleared by the provider/orthopedics.
Category reason: This item tests nursing judgment about which provider order is potentially unsafe in a client with osteomyelitis and could increase complications, fitting Reduction of Risk Potential—Potential for Complications.

Question 10

A G3P2 at 20 weeks reports sudden loss of fluid and cramping. Sterile speculum exam confirms PPROM. What is the priority nursing action?

Accepted Answer

Answer reason: PPROM at 20 weeks places the pregnant client at high risk for serious complications, especially intrauterine infection (chorioamnionitis) and preterm birth. Priority nursing action is to support evidence-based management aimed at reducing infection risk and improving fetal outcomes, which includes initiating ordered broad-spectrum antibiotics and, when appropriate per protocol, corticosteroids to promote fetal lung maturity. Induction is not the immediate priority in the absence of clear indications (e.g., infection, fetal compromise), and ambulation can increase risk of cord prolapse or worsen leakage. Fundal massage is a postpartum intervention for uterine atony and is not appropriate here.
Category reason: This is a patient-care priority/intervention question about managing PPROM to prevent maternal-fetal complications, which fits NCLEX nursing judgment under monitoring and preventing potential complications.

Question 11

A client at 28 weeks with HELLP syndrome has platelets of 70,000 and elevated liver enzymes. What should the nurse expect to monitor closely?

Accepted Answer

Answer reason: HELLP syndrome is a severe form of preeclampsia with hemolysis, elevated liver enzymes, and thrombocytopenia, placing the client at high risk for rapid maternal deterioration. Urine output must be monitored closely because oliguria can indicate worsening renal perfusion and impending complications such as acute kidney injury. Reflexes are assessed to monitor neurologic irritability and progression toward eclampsia and to help detect magnesium sulfate toxicity if it is being administered. The other options (blood glucose, fetal position, hemoglobin A1C) are not priority surveillance parameters for acute HELLP-related complications.
Category reason: This item focuses on nursing monitoring to detect and prevent complications of a high-risk obstetric condition (HELLP/preeclampsia), which is best classified under NCLEX Reduction of Risk Potential—Potential for Complications.

Question 12

Which postpartum client is at highest risk for developing a DVT?

Accepted Answer

Answer reason: Postpartum clients are hypercoagulable, and risk of DVT increases further with venous stasis and vascular injury. A cesarean section adds surgical endothelial trauma and typically more immobility than a vaginal birth. Being on bed rest significantly increases venous stasis, making this client the highest risk. Exclusive breastfeeding and mild anemia are not major independent DVT risk factors compared with surgery plus immobility.
Category reason: The question asks the nurse to identify which postpartum patient has the greatest risk for a complication (DVT) based on clinical risk factors, aligning with nursing surveillance and prevention of complications.

Question 13

A nurse is caring for a client with increased intracranial pressure (ICP). Which of the following should the nurse implement?

Accepted Answer

Answer reason: Elevating the head of the bed to about 30 degrees promotes venous drainage from the brain and can help decrease intracranial pressure while maintaining cerebral perfusion. Keeping the bed flat or placing the client in Trendelenburg can impede venous outflow and worsen ICP. Encouraging coughing and deep breathing can transiently increase intrathoracic and intracranial pressure, so it is not recommended when ICP is elevated unless specifically indicated and managed.
Category reason: The question focuses on a nursing intervention to prevent worsening of a complication (elevated ICP) and to reduce risk of further neurologic deterioration, which aligns with monitoring and preventing complications under Reduction of Risk Potential.

Question 14

A nurse is caring for a patient with a newly applied long leg cast. Which finding should the nurse report immediately?

Accepted Answer

Answer reason: Pale toes with an absent pulse after cast application indicates compromised distal circulation and possible acute neurovascular compromise (e.g., arterial occlusion/compartment syndrome). This is an emergency because prolonged ischemia can lead to tissue necrosis and permanent loss of function. Pain alone at 6/10 can be expected after casting, and warm toes with brisk capillary refill is reassuring. A “heavy” feeling can occur from the cast itself and is not as immediately dangerous as absent pulses with pallor.
Category reason: This item tests nursing recognition of a serious post-cast complication (neurovascular compromise) and the need for urgent reporting/intervention, which fits Potential for Complications under Reduction of Risk Potential.

Question 15

Which sign indicates fat embolism syndrome (FES) in a client with a femur fracture?

Accepted Answer

Answer reason: Fat embolism syndrome is a serious complication of long-bone fractures (e.g., femur) caused by fat globules entering the circulation. A classic and relatively specific finding is a petechial rash, often on the chest, axillae, or conjunctiva, due to capillary occlusion and platelet aggregation. Vital sign changes in FES more typically include respiratory distress, hypoxemia, tachycardia, and neurologic changes rather than isolated hypertension or bradycardia. Jaundice is not a hallmark sign used to identify FES in this context.
Category reason: The question tests recognition of a life-threatening complication (fat embolism syndrome) associated with a femur fracture, requiring nursing surveillance for complications rather than foundational anatomy/physiology knowledge.

Question 16

A client with a pelvic fracture has no urinary output for 6 hours. What is the nurse’s priority action?

Accepted Answer

Answer reason: A pelvic fracture places the client at high risk for genitourinary injury (e.g., urethral/bladder trauma) and/or internal bleeding leading to decreased renal perfusion; 6 hours of anuria is not normal and suggests a potentially serious complication. Inserting a urinary catheter may be contraindicated if urethral injury is possible and should be done only with provider direction and appropriate evaluation. Repositioning would not address likely obstruction or injury, and documenting as normal is unsafe. The priority is to promptly notify the healthcare provider for urgent assessment and orders.
Category reason: This is a nursing-priority question focused on recognizing and responding to a potential complication (anuria after pelvic fracture) and initiating appropriate escalation of care, which fits Reduction of Risk Potential—Potential for Complications.

Question 17

Nurse Edwards is providing discharge instructions to a client with a newly implanted pacemaker. Which self-monitoring activity should the nurse emphasize?

Accepted Answer

Answer reason: Clients with a pacemaker should be taught to regularly monitor and record their pulse to detect bradycardia, tachycardia, or an irregular rhythm that may indicate pacemaker malfunction or dysrhythmia. A sustained pulse outside parameters set by the provider should prompt contacting the healthcare team. Daily blood pressure and reporting ankle edema may be relevant for comorbid cardiovascular disease but are not the key pacemaker-specific self-check. Avoiding microwave ovens is outdated guidance because modern pacemakers are shielded and household microwaves are generally safe.
Category reason: The question focuses on discharge teaching to prevent/identify complications after a pacemaker implantation, which is a nursing safety/monitoring intervention rather than foundational biomedical science.

Question 18

Nurse Taylor is admitting a child who has just returned from surgery following a tonsillectomy. What should be the priority nursing diagnosis for this child?

Accepted Answer

Answer reason: Immediately after tonsillectomy, airway protection is the highest priority because anesthesia effects, bleeding, and impaired gag/swallow reflex increase the risk of aspiration. Aspiration can rapidly lead to airway obstruction, hypoxia, and respiratory compromise, making it more urgent than pain or communication issues. While pain is expected and should be managed, it is addressed after ensuring the child can maintain a patent airway and safely handle secretions.
Category reason: This question asks for priority nursing diagnosis and focuses on preventing a serious postoperative complication (airway/aspiration) in a child, which requires nursing judgment about risk and monitoring. That aligns with NCLEX Physiological Integrity—Reduction of Risk Potential, especially identifying and preventing postoperative complications.

Question 19

A nurse is caring for a client with a new long leg cast. Which assessment finding requires immediate action?

Accepted Answer

Answer reason: A capillary refill time of 4 seconds indicates compromised distal perfusion and is concerning for neurovascular impairment or developing compartment syndrome in a newly casted extremity. This finding requires prompt intervention (e.g., elevate to heart level, assess pulses/sensation/movement, notify provider, and anticipate cast bivalving) to prevent ischemia and tissue necrosis. Mild pain with movement and some toe swelling can be expected early after casting, and warmth under the cast is not as specific for impaired circulation. Delayed capillary refill is the most urgent, limb-threatening sign among the options.
Category reason: The question tests nursing assessment and recognition of urgent complications (impaired circulation/compartment syndrome) related to casting, which is a patient-safety and complication-prevention decision typical of NCLEX clinical judgment.

Question 20

A nurse is caring for a client with a fractured femur in skeletal traction. Which assessment finding requires immediate intervention?

Accepted Answer

Answer reason: Absence of a dorsalis pedis pulse indicates compromised distal perfusion to the affected leg, which can reflect acute neurovascular compromise from traction, swelling, arterial injury, or evolving compartment syndrome. This is limb-threatening and requires immediate intervention (reassess neurovascular status, notify provider, and address traction alignment/tension per protocol). In contrast, clear drainage at a pin site may be expected early, capillary refill

Question 21

After total hip replacement, which activity should the client avoid?

Accepted Answer

Answer reason: After total hip replacement, clients must avoid hip adduction and internal rotation because these positions can dislocate the prosthetic hip. Crossing the legs at the knees places the hip in adduction and increases dislocation risk, especially in the early postoperative period. In contrast, using a raised toilet seat, sitting in appropriate chairs, and using a walker support safe positioning and mobility while protecting the joint.
Category reason: This question tests postoperative nursing teaching and safety measures to prevent a major complication (hip dislocation) after a surgical procedure, which fits Reduction of Risk Potential—Potential for Complications.

Question 22

QS1. The nurse receives report on four endocrine patients. Who should the nurse see first?

Accepted Answer

Answer reason: Perioral tingling after thyroidectomy is a classic early sign of hypocalcemia from inadvertent parathyroid injury or removal, which can rapidly progress to tetany, laryngospasm, seizures, and airway compromise. This represents an acute, potentially life-threatening postoperative complication requiring immediate assessment and likely calcium replacement. The other clients have mildly elevated glucose or chronic symptoms that are not immediately dangerous.
Category reason: This is a nursing prioritization question focused on recognizing and responding first to an acute postoperative complication risk (hypocalcemia after thyroidectomy), which fits NCLEX patient-care decision-making under potential complications.

Question 23

Which of the following findings in a client with severe preeclampsia is most concerning?

Accepted Answer

Answer reason: A platelet count of 50,000 indicates severe thrombocytopenia and strongly suggests progression toward HELLP syndrome and/or disseminated intravascular coagulation, creating an immediate risk for maternal hemorrhage and organ injury. This degree of thrombocytopenia is a critical complication that can rapidly worsen and requires urgent provider notification and escalation of care. While proteinuria, epigastric pain, and visual disturbances are concerning features of severe preeclampsia, they are less immediately life-threatening than profound thrombocytopenia. Therefore, the low platelet count is the most concerning finding.
Category reason: This question tests nursing recognition of a dangerous complication and interpretation of a critical clinical finding in severe preeclampsia to determine what requires the most urgent response, which aligns with monitoring for and preventing complications.

Question 24

Which action should the nurse take for a Rh-negative mother with no Rhogam at 28 weeks and now presents after a fall?

Accepted Answer

Answer reason: After maternal trauma (e.g., a fall), an Rh-negative pregnant client is at risk for fetomaternal hemorrhage, which can lead to Rh sensitization if the fetus is Rh-positive. If the mother is not already sensitized (no anti-D antibodies), Rho(D) immune globulin should be administered promptly to prevent antibody formation. Checking fetal heart tones alone or simply reassuring does not address the risk of alloimmunization. Waiting until delivery increases the chance of sensitization and hemolytic disease in this or future pregnancies.
Category reason: This question tests the nurse’s intervention to prevent a pregnancy-related complication (Rh alloimmunization) after a triggering event (trauma), which aligns with monitoring/preventing potential complications under Reduction of Risk Potential.

Question 25

A patient with a chest tube for pneumothorax has continuous bubbling in the water-seal chamber. What is the most appropriate action?

Accepted Answer

Answer reason: In a chest tube system, continuous bubbling in the water-seal chamber indicates an air leak, which is abnormal (intermittent bubbling may occur early with pneumothorax). The priority nursing action is to assess the system for leaks (connections, tubing integrity, insertion site) to prevent loss of negative intrathoracic pressure and ineffective lung re-expansion. Routine clamping is unsafe because it can rapidly lead to tension pneumothorax if air cannot escape. Therefore, checking for an air leak in the system is the most appropriate action.
Category reason: This question tests nursing management of a chest tube complication (continuous bubbling suggesting an air leak) and the safest immediate action to prevent harm, which fits NCLEX Physiological Integrity—Reduction of Risk Potential (Potential for Complications).

Question 26

The nurse observes a newly applied skeletal traction. Which action is correct?

Accepted Answer

Answer reason: Skeletal traction must maintain a continuous, uninterrupted pull to achieve alignment and prevent complications such as impaired healing or neurovascular compromise. Ropes should hang freely and move smoothly through the pulleys so the prescribed force is transmitted accurately. Weights should hang freely and not rest on the floor, and traction should not be removed routinely because it interrupts alignment. Ropes also should not be tied to the bed frame, as that prevents proper traction mechanics.
Category reason: This question tests correct nursing management of traction equipment to prevent complications from interrupted or ineffective traction, which is a patient-safety/risk-reduction nursing intervention topic.

Question 27

Which finding is an early sign of fat embolism syndrome in a client with femur fracture?

Accepted Answer

Answer reason: Fat embolism syndrome is a serious complication of long-bone fractures and classically presents with early respiratory findings (e.g., chest pain, dyspnea/hypoxemia) and a petechial rash due to embolized fat and platelet aggregation. These findings reflect acute pulmonary involvement and microvascular occlusion, which occur early in the syndrome. Bradycardia is not a typical early hallmark, urinary retention is unrelated, and bleeding from an IV site suggests coagulopathy rather than the classic early presentation of fat embolism.
Category reason: This item tests recognition of an acute, potentially life-threatening complication following a femur fracture (fat embolism) and the nurse’s ability to identify early warning signs, which aligns with monitoring for complications under Reduction of Risk Potential.

Question 28

Which assessment finding indicates impaired circulation in a limb casted for a fracture?

Accepted Answer

Answer reason: Neurovascular compromise after casting is suggested by paresthesia (tingling) and delayed capillary refill, indicating decreased arterial perfusion to the distal limb. This can occur from swelling under a tight cast and may progress to ischemia or compartment syndrome if not addressed promptly. Warm skin, pink nail beds, and strong bounding pulses are more consistent with adequate perfusion rather than impaired circulation. Sluggish cap refill is an early, actionable sign requiring urgent reassessment of cast tightness and elevation/notification of the provider.
Category reason: The question tests nursing assessment for a serious post-casting complication (impaired circulation/neurovascular compromise) and the need to recognize risk early, which fits Reduction of Risk Potential—Potential for Complications.

Question 29

A client with osteomyelitis is receiving long-term antibiotics. What is the nurse's priority action?

Accepted Answer

Answer reason: Long-term antibiotic therapy for osteomyelitis carries significant risk for drug toxicity, including nephrotoxicity (notably with agents such as aminoglycosides and vancomycin). The nurse’s priority is ongoing monitoring to detect complications early, so monitoring kidney function tests (e.g., BUN/creatinine) is essential. Fluid restriction is generally not indicated and can worsen renal perfusion, antacids may interfere with absorption of certain antibiotics, and cold compresses do not address the primary safety risk of systemic therapy.
Category reason: The question focuses on a nursing priority action to prevent or identify complications from long-term antibiotic therapy, which is a patient-safety/monitoring judgment in clinical care rather than foundational biomedical knowledge.

Question 30

After total hip replacement, which action by the nurse is appropriate?

Accepted Answer

Answer reason: After a total hip replacement, the priority is preventing hip dislocation by maintaining proper alignment and avoiding hip adduction and internal rotation. An abduction pillow helps keep the legs separated and the hip in a neutral, safe position during turning and repositioning. Crossing the legs promotes adduction and increases dislocation risk, and flexing the hip beyond 90° while sitting is also a standard precaution to avoid posterior dislocation.
Category reason: The question tests postoperative nursing interventions to prevent a serious complication (hip prosthesis dislocation) through safe positioning and turning techniques, which aligns with Reduction of Risk Potential—Potential for Complications.

Question 31

After femoral cardiac catheterization, a client reports numbness in the leg. What is the nurse's first action?

Accepted Answer

Answer reason: Post–femoral cardiac catheterization leg numbness can indicate impaired distal perfusion from arterial spasm, thrombosis, embolus, or a developing hematoma compressing neurovascular structures. The nurse’s priority is to assess circulation to the affected extremity immediately by checking pedal pulses (and comparing bilaterally), along with color, temperature, capillary refill, and sensation. This rapid assessment determines urgency and guides escalation; notifying the provider follows abnormal findings. Reassurance or documentation alone delays identification of a potentially limb-threatening complication.
Category reason: The question tests a nurse’s immediate post-procedure assessment and recognition of neurovascular compromise after an invasive vascular procedure, which is focused on preventing and detecting complications (Reduction of Risk Potential).

Question 32

The nurse is teaching cast care. Which statement indicates correct understanding?

Accepted Answer

Answer reason: Numbness or burning in the fingers can indicate neurovascular compromise from swelling or a cast that is too tight, which is a potential complication requiring prompt evaluation. Early reporting helps prevent progression to impaired circulation, nerve damage, or compartment syndrome. The other statements reflect unsafe or incorrect care (inserting objects under the cast, continuously covering the cast risking moisture/skin breakdown, and keeping the arm dependent rather than elevating to reduce swelling).
Category reason: This item tests nursing teaching and recognition of complications of casting (neurovascular compromise) and appropriate client instructions to reduce risk, which aligns with Potential for Complications.

Question 33

A postpartum client is complaining of intense perineal pain, but the fundus is firm, and bleeding is minimal. What should the nurse suspect?

Accepted Answer

Answer reason: Severe, intense perineal pain with a firm uterine fundus and minimal vaginal bleeding suggests concealed bleeding rather than uterine atony. A perineal hematoma can cause significant pressure and pain as blood accumulates in the tissues while external bleeding remains small. Uterine atony typically presents with a boggy uterus and heavy lochia, and endometritis more often presents with uterine tenderness and fever. Therefore the most likely complication is a perineal hematoma.
Category reason: This question tests nursing recognition of a postpartum complication based on assessment findings (pain pattern, fundal tone, and bleeding) and requires clinical judgment to identify a likely complication, which aligns with NCLEX-focused patient assessment and risk detection.

Question 34

After tonsillectomy, child is kept in which position?

Accepted Answer

Answer reason: Immediately after tonsillectomy, the priority is maintaining a patent airway and preventing aspiration of blood and secretions. Positioning the child prone (or side-lying) with the head turned to the side promotes drainage from the mouth and keeps secretions from pooling in the pharynx. Supine positioning increases the risk of airway obstruction and aspiration if bleeding occurs. Fowler’s can be used later when fully awake, but the safest immediate post-op position is prone with head to the side.
Category reason: This question tests a postoperative nursing intervention aimed at preventing complications (airway obstruction/aspiration) after surgery, which fits Reduction of Risk Potential—Potential for Complications.

Question 35

A patient on bed rest is at risk for which complication?

Accepted Answer

Answer reason: Prolonged bed rest causes venous stasis in the lower extremities, increasing the risk of thrombus formation and therefore deep vein thrombosis. Immobility is a classic component of Virchow’s triad (stasis), making DVT a common and clinically significant complication to anticipate and prevent. While orthostatic hypotension can occur with immobility, DVT is the more characteristic complication of sustained bed rest. Hypertension and increased metabolism are not expected physiologic consequences of bed rest.
Category reason: The question tests a nursing safety focus: anticipating and preventing an immobility-related complication (DVT) during bed rest, which aligns with monitoring for and reducing risk of complications.

Question 36

A woman with placenta previa is bleeding. What is the most appropriate position for her?

Accepted Answer

Answer reason: In a bleeding placenta previa, positioning should optimize maternal hemodynamics and uteroplacental perfusion while avoiding aortocaval compression. The left lateral position displaces the gravid uterus off the inferior vena cava, improving venous return and cardiac output. Supine positioning can worsen hypotension and reduce placental perfusion; prone and Semi-Fowler’s are not preferred for maximizing uteroplacental blood flow in this context.
Category reason: This is a patient-care safety/intervention question focused on preventing maternal/fetal compromise (a potential complication) through appropriate positioning in an obstetric hemorrhage scenario, which aligns with NCLEX nursing management of complications.

Question 37

Q.4 The nurse administer nasogastric tube feeding slowly to avoid the risk of

Accepted Answer

Answer reason: Administering tube feeding too quickly increases gastric volume and pressure, which can trigger regurgitation and raise aspiration risk. Slow administration allows better gastric accommodation and reduces reflux into the esophagus. While abdominal distension and discomfort can also occur with rapid feeding, preventing regurgitation/aspiration is the most critical safety concern. Therefore, regurgitation is the best answer.
Category reason: This item asks about a nursing intervention (administering NG tube feeding slowly) to prevent a complication (regurgitation/aspiration), which is a patient-safety risk-reduction concern rather than foundational science.

Question 38

A nurse is reviewing post-procedure care for a client who just returned from a liver biopsy. Which action is most appropriate?

Accepted Answer

Answer reason: After a liver biopsy, the priority is to reduce the risk of hemorrhage from the puncture site. Placing the client on the right side (biopsy side down) provides pressure to the liver capsule and helps tamponade bleeding. High Fowler’s can increase strain and does not protect the biopsy site, and routine NPO for 12 hours is not required unless otherwise ordered. Hematuria is not the expected key complication for liver biopsy (it is more associated with renal procedures); monitoring should focus on bleeding and signs of shock.
Category reason: The item tests nursing post-procedure positioning and monitoring to prevent a serious complication (bleeding) after an invasive procedure, which aligns with Reduction of Risk Potential—Potential for Complications.

Question 39

A nurse from Manchester assesses a patient who develops sudden severe shortness of breath and oxygen saturation 82% on 15L non-rebreather after long bone fracture. What's the immediate suspicion?

Accepted Answer

Answer reason: After a long-bone fracture, acute hypoxemia and sudden respiratory distress strongly suggest fat embolism syndrome due to marrow fat entering the circulation and lodging in the pulmonary microvasculature. Classically it develops within 24–72 hours after injury, and early findings are respiratory compromise with hypoxia that can be severe despite high-flow oxygen. While pulmonary embolism and pneumothorax can also cause sudden dyspnea, the specific association with long-bone fracture makes fat embolism syndrome the most likely immediate suspicion among the options.
Category reason: The question tests nursing recognition of a serious post-fracture complication and the need for rapid assessment/escalation, which aligns with identifying potential complications under Reduction of Risk Potential.

Question 40

A cuffed tracheostomy tube is primarily used to?

Accepted Answer

Answer reason: A cuffed tracheostomy tube is used to create a seal in the trachea so positive-pressure ventilation can be delivered effectively and to reduce gross aspiration of oral or gastric secretions into the lower airway. While a cuff does not completely eliminate aspiration risk (microaspiration can still occur), preventing aspiration into the lungs is the primary safety purpose compared with the other options. Speaking typically requires airflow through the larynx and is more associated with cuff deflation or a speaking valve rather than an inflated cuff. The cuff does not primarily prevent dislodgement or reduce mucus production.
Category reason: This item tests nursing knowledge of airway device purpose and complication prevention (aspiration/airway protection) rather than basic anatomy or physiology, fitting NCLEX reduction of risk and prevention of respiratory complications.

Question 41

A nurse is providing care for a newborn diagnosed with a cephalohematoma on the left side of the head. Which of the following interventions should the nurse prioritize?

Accepted Answer

Answer reason: A cephalohematoma is a subperiosteal bleed; as the blood breaks down, the newborn is at increased risk for hyperbilirubinemia and jaundice. Prioritizing monitoring for jaundice allows early detection and treatment (e.g., timely bilirubin checks and phototherapy if indicated) to prevent bilirubin-related neurotoxicity. Pressure dressings are not recommended because they do not resolve the bleed and may cause skin breakdown. Antibiotics are not indicated unless there is evidence of infection, and elevating the head of the bed does not address the primary complication risk.
Category reason: This item tests nursing monitoring and prevention of a common complication (hyperbilirubinemia) associated with a newborn condition, which aligns with identifying and reducing risk for complications.

Question 42

Halfway through the administration of blood, the female client complains of lumbar pain. After stopping the infusion Nurse Hazel should?

Accepted Answer

Answer reason: New-onset lumbar/flank pain during a blood transfusion is a classic sign of an acute hemolytic transfusion reaction, which can rapidly progress to shock, hemoglobinuria, and DIC. After immediately stopping the blood, the priority is to keep the IV line patent with 0.9% normal saline via new tubing so emergency medications/fluids can be administered and hypotension can be treated. Vital signs and notification of the blood bank are essential next steps, but maintaining IV access with saline is the most urgent action after stopping the transfusion. Further pain assessment should not delay reaction management.
Category reason: This question tests nursing actions to recognize and manage a potentially life-threatening transfusion reaction and prevent deterioration, which fits NCLEX-focused complication prevention and monitoring.

Question 43

The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self-care management. Which statement, if made by the client, indicates a need for further instruction?

Accepted Answer

Answer reason: Arterial ischemic ulcers reflect poor arterial perfusion, so elevating the leg above heart level can further reduce arterial blood flow to the distal extremity and worsen ischemic pain and tissue perfusion. Teaching for arterial disease emphasizes keeping the limb dependent or at least not elevated above the heart, and protecting feet from trauma and extreme temperatures. The other statements are consistent with safe foot care to reduce risk of injury and infection (avoid barefoot walking, cut nails straight across, moisturize but avoid moisture between toes to prevent maceration). Therefore, the elevation instruction indicates misunderstanding and needs further teaching.
Category reason: This item tests nursing teaching to prevent complications of an arterial ischemic leg ulcer and reduce risk of worsening perfusion/injury, which aligns with monitoring and preventing potential complications in Physiological Integrity.

Question 44

A laboring client at 39 weeks gestation is receiving oxytocin for induction. The nurse notes uterine contractions occurring every 1–2 minutes, lasting 90 seconds, with minimal resting tone between contractions. What is the nurse’s priority action?

Accepted Answer

Answer reason: Contractions every 1–2 minutes lasting 90 seconds with minimal relaxation indicates uterine tachysystole/hyperstimulation from oxytocin, which can reduce uteroplacental perfusion and cause fetal hypoxemia. The nurse’s first priority is to remove the cause by stopping the oxytocin infusion. Notifying the provider is appropriate after immediate corrective action, and pain medication does not address the dangerous pattern. Continued monitoring alone delays treatment of a potentially emergent complication.
Category reason: This item tests nursing recognition of an oxytocin-related complication (uterine tachysystole) and the immediate safety intervention to prevent maternal-fetal harm, which fits NCLEX patient-care risk reduction and complication prevention.

Question 45

Which is the "danger sign" of pregnancy?

Accepted Answer

Answer reason: Blurred vision during pregnancy is a danger sign because it can indicate severe preeclampsia, a hypertensive disorder that may involve cerebral/retinal vasospasm and can progress to eclampsia and stroke. This symptom warrants urgent assessment of blood pressure, urine protein, neurologic status, and fetal well-being. In contrast, mild dependent pedal edema, heartburn, and nausea/vomiting are common discomforts of uncomplicated pregnancy and are not, by themselves, danger signs.
Category reason: The question asks the nurse to recognize a pregnancy warning sign that signals a serious maternal complication requiring prompt evaluation, which aligns with monitoring for and preventing complications.

Question 46

Which position is recommended after a liver biopsy?

Accepted Answer

Answer reason: After a percutaneous liver biopsy, the priority is reducing the risk of hemorrhage from the puncture site. Placing the client in the right lateral (right side-lying) position applies pressure to the liver biopsy site and helps tamponade bleeding. This position is typically maintained for the initial post-procedure period while monitoring vital signs and signs of internal bleeding.
Category reason: This question tests a post-procedure nursing intervention aimed at preventing a serious complication (bleeding) following an invasive diagnostic procedure, which fits Reduction of Risk Potential—Potential for Complications.

Question 47

A nurse is monitoring a client with a chest tube. Which finding requires immediate intervention?

Accepted Answer

Answer reason: Continuous bubbling in the water seal chamber indicates an air leak in the chest tube system (from loose connections, a cracked drainage unit, or leakage at the insertion site), which can prevent effective lung re-expansion and risk worsening pneumothorax. This finding requires prompt troubleshooting of the system and assessment of the client. Tidaling is expected with normal respirations, an intact dressing is appropriate, and 75 mL drainage in the first hour is generally within expected postoperative/initial ranges unless excessive or rapidly increasing.
Category reason: The question tests nursing monitoring and immediate action for complications of chest tube therapy, which is a patient-care safety issue rather than foundational science knowledge; this fits NCLEX Reduction of Risk Potential (Potential for Complications).

Question 48

A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse would take which most appropriate action?

Accepted Answer

Answer reason: In the immediate postoperative period after a gastrectomy, small amounts of dark or bloody nasogastric drainage can be an expected finding due to surgical site oozing. The appropriate nursing action is to continue to monitor the amount, color, and trend, and assess the patient for signs of hemorrhage (tachycardia, hypotension, increasing NG output). Irrigating the NG tube is typically avoided unless specifically prescribed because it can disrupt the anastomosis and increase bleeding risk. The surgeon should be notified if drainage becomes bright red, rapidly increases, or the patient shows hemodynamic instability.
Category reason: This is a postoperative nursing management question focused on recognizing expected vs concerning findings and preventing/identifying complications after surgery, which aligns with Potential for Complications under Reduction of Risk Potential.

Question 49

A patient in septic shock is receiving norepinephrine via central line. The nurse notices that the urine output has dropped to 10 mL/hr. What is the best nursing action?

Accepted Answer

Answer reason: Urine output of 10 mL/hr in septic shock suggests possible worsening renal perfusion or inadequate hemodynamic support, but the nurse should first assess and trend objective data (BP/MAP, HR, capillary refill, mental status, lactate trends if available, and urine output pattern) to determine severity and guide next steps. Immediate actions like increasing fluids or titrating norepinephrine depend on current MAP/volume status and provider orders/protocol targets, so assessment is the safest first step. After confirming hypotension/low MAP or other signs of poor perfusion, the nurse can then implement protocol-based titration and promptly notify the provider with a focused report.
Category reason: This is a patient-care prioritization/intervention question in an ICU scenario, focusing on nursing assessment and monitoring for complications of septic shock (end-organ hypoperfusion). That aligns with NCLEX Physiological Integrity—Reduction of Risk Potential, specifically identifying and responding to potential complications.

Question 50

The parents of an infant who has had a surgical repair of a myelomeningocele express concern about skin care and ask what they can do to avoid problems. The nurse should teach the parents that their infant?

Accepted Answer

Answer reason: After myelomeningocele repair, infants remain at risk for ongoing complications such as neurogenic bowel/bladder, lower-extremity deficits, pressure injury due to impaired sensation/mobility, and shunt-related issues if hydrocephalus is present. Preventing skin breakdown requires comprehensive, long-term management rather than a single diapering measure. Indefinite prophylactic antibiotics are not routine, and applying powder after each diaper change is not recommended because powders can irritate skin and pose inhalation risks. Routine cleansing alone is insufficient because risk is driven by neurologic impairment and need for coordinated follow-up.
Category reason: This item tests nursing teaching to reduce the risk of complications and skin breakdown after a congenital neurologic defect repair, which is a patient-care judgment topic rather than foundational science.

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