Question 1

Nurse Lucy is planning to give preoperative teaching to a client who will be undergoing rhinoplasty. Which of the following should be included?

Accepted Answer

Answer reason: Preoperative teaching for rhinoplasty should include avoiding aspirin and other salicylates because they inhibit platelet aggregation and increase the risk of perioperative bleeding. Stopping aspirin about 1–2 weeks before surgery is commonly recommended to allow new platelets to replace inhibited ones. The other options are inaccurate: postoperative swelling and dressings limit immediate visibility of results, saline drops are typically used postoperatively to moisturize/cleanse, and nasal packing is usually removed within a few days rather than 8–10 days.
Category reason: This is a perioperative nursing teaching and safety question focused on preventing surgical complications (bleeding risk) through medication avoidance, which fits NCLEX Reduction of Risk Potential—Potential for Complications.

Question 2

Common post-op complications after hip surgery:

Accepted Answer

Answer reason: After hip surgery, patients are at high risk for venous thromboembolism due to immobility, endothelial injury from surgery, and a postoperative hypercoagulable state. Therefore, DVT is a common and clinically important postoperative complication to anticipate and prevent with early ambulation and prophylaxis. UTI can occur (often related to catheter use), but DVT is more directly linked to major orthopedic procedures. Stroke and hematemesis are not typical common complications specifically associated with routine hip surgery.
Category reason: The question tests recognition of a frequent postoperative complication and the nurse’s need to monitor/prevent it in a surgical patient, which fits Reduction of Risk Potential (Potential for Complications).

Question 3

Which of the following is a sign of tracheostomy tube obstruction?

Accepted Answer

Answer reason:  Increased respiratory effort and noisy breathing Tracheostomy tube obstruction commonly presents with signs of increased work of breathing (dyspnea, use of accessory muscles) and turbulent airflow causing noisy respirations/stridor. As obstruction worsens, ventilation becomes inadequate and oxygenation declines, prompting respiratory distress. Bradycardia and decreased respiratory rate are later, ominous signs of severe hypoxia and impending respiratory failure rather than early indicators. Clear breath sounds would not suggest an obstructed airway.
Category reason: This item tests nursing recognition of a potentially life-threatening airway complication (tracheostomy obstruction) and the associated assessment findings, which fits monitoring for complications under Reduction of Risk Potential.

Question 4

What is your priority intervention?

Accepted Answer

Answer reason:  b. Cover the wound with sterile saline-moistened gauze and notify the surgeon. This presentation is most consistent with wound dehiscence/evisceration risk, where the immediate priority is to protect exposed tissue and prevent drying/contamination using sterile saline-moistened dressings while urgently notifying the surgeon. Applying pressure can damage tissue and worsen the complication. Reassurance/vitals and positioning/calling for help are supportive actions but do not address the time-critical need to cover and protect the wound.
Category reason: This question tests a nursing priority intervention to prevent and manage a postoperative wound complication (dehiscence/evisceration), which fits Reduction of Risk Potential—Potential for Complications.

Question 5

A nurse is caring for a patient with COPD. Which oxygen delivery system is most appropriate?

Accepted Answer

Answer reason:  D) Venturi mask In COPD, oxygen should be delivered in a controlled, precise FiO2 to avoid worsening hypercapnia while still treating hypoxemia. A Venturi mask provides the most accurate and consistent FiO2 (e.g., 24–28%) compared with nasal cannula or simple masks, making it the safest choice when tight oxygen titration is needed. A non-rebreather delivers very high FiO2 and is typically reserved for acute, severe hypoxemia or emergencies rather than routine COPD management.
Category reason: This is a nursing clinical decision about selecting the safest oxygen delivery device to prevent respiratory complications in a COPD patient, which aligns with preventing/monitoring potential complications under Reduction of Risk Potential.

Question 6

The nurse should place the child who had a tonsillectomy in which position?

Accepted Answer

Answer reason:  Side-lying position. After tonsillectomy, positioning the child side-lying helps maintain a patent airway and allows blood and secretions to drain out of the mouth rather than being aspirated. This reduces the risk of airway obstruction and aspiration, especially if postoperative bleeding occurs. Supine positioning increases aspiration risk, and Trendelenburg is not appropriate for airway protection in this situation; High-Fowler’s may be used when awake but side-lying is the safest immediate recovery position.
Category reason: This is a nursing care question focused on postoperative positioning to prevent aspiration and airway complications after a procedure, which fits NCLEX Reduction of Risk Potential—Potential for Complications.

Question 7

A client who has a cold is seen in the emergency department with an inability to void. Because the client has a history of benign prostatic hyperplasia, the nurse determines that the client should be questioned about the use of which medication?

Accepted Answer

Answer reason: Decongestants. Many OTC cold decongestants (especially alpha-adrenergic agonists like pseudoephedrine or phenylephrine) can increase smooth muscle tone in the bladder neck and prostate, worsening urinary retention in clients with BPH. This can precipitate acute inability to void and requires prompt assessment and intervention. The other medication classes listed are not typical triggers of acute urinary retention in the setting of a cold.
Category reason: This question tests nursing assessment of medication use and risk factors that can precipitate a complication (acute urinary retention) in a client with BPH, which aligns with monitoring and preventing complications.

Question 8

The nurse is caring for a client who is undergoing chemotherapy. Which of the following side effects should the nurse monitor for?

Accepted Answer

Answer reason: Neutropenia Many chemotherapeutic agents suppress bone marrow function, leading to decreased neutrophil counts (neutropenia). This places the client at high risk for infection and sepsis, making monitoring of CBC/ANC and assessment for fever crucial. Hypertension, weight gain, and hyperglycemia can occur with certain medications (e.g., steroids), but neutropenia is a common and priority complication directly associated with chemotherapy.
Category reason: This item tests nursing monitoring for a high-risk complication of chemotherapy (myelosuppression/infection risk), which is a patient-safety surveillance and complication-prevention focus under Reduction of Risk Potential.

Question 9

The nurse is reviewing the laboratory results of a child scheduled for tonsillectomy. Which laboratory value would be significant to review?

Accepted Answer

Answer reason: Platelet count. Tonsillectomy is a surgical procedure with a key perioperative risk of hemorrhage, so assessing hemostasis is critical. A platelet count helps identify thrombocytopenia or platelet-related bleeding risk that could increase perioperative and postoperative bleeding. Creatinine and BUN primarily assess renal function, and a general urinalysis is not as directly tied to the main immediate surgical complication risk as bleeding.
Category reason: This is a preoperative nursing judgment question focused on identifying lab results most relevant to preventing surgical complications (bleeding) in a scheduled procedure, which fits Reduction of Risk Potential—Potential for Complications.

Question 10

The nurse is planning to put aneurysm precautions in place for the client with a cerebral aneurysm. Which item should be included as part of the precautions?

Accepted Answer

Answer reason: Maintaining the head of the bed at 15 degrees. For a client with a cerebral aneurysm, precautions aim to prevent increases in intracranial pressure and reduce risk of rupture/bleeding by minimizing stimulation and hemodynamic surges. Keeping the head of the bed slightly elevated (often around 15–30 degrees depending on orders and neurologic status) supports venous drainage and helps avoid abrupt ICP changes. The other options permit vasoconstrictive or stimulant exposures (nicotine, caffeine) or increased activity, which can elevate blood pressure and precipitate complications.
Category reason: This is a nursing-care question focused on implementing precautionary interventions to reduce the risk of complications (rupture/bleeding, increased ICP) in a client with a cerebral aneurysm, which aligns with Reduction of Risk Potential—Potential for Complications.

Question 11

A nurse is monitoring an infant receiving phototherapy. Which finding should be reported to the healthcare provider immediately?

Accepted Answer

Answer reason: Decreased urine output Phototherapy can increase insensible water loss, raising the risk of dehydration, so decreased urine output is an urgent sign of inadequate hydration and potential complications. This requires prompt evaluation and possible adjustment of fluids/feeding or therapy. Increased stool output is a common expected effect during phototherapy, and a temperature of 36.8°C is normal. Persistent yellowing can be consistent with jaundice and does not, by itself, represent an immediate complication compared with oliguria.
Category reason: This item tests nursing monitoring and prompt recognition/escalation of a complication (dehydration) during an infant therapy, which is a patient-care safety judgment consistent with NCLEX Reduction of Risk Potential (Potential for Complications).

Question 12

A gravida 2 para 1 client delivered a full-term newborn 12 hours ago. The nurse finds her uterus to be boggy, high, and deviated to the right. The most appropriate nursing action's to:

Accepted Answer

Answer reason: Have the client void and then re-evaluate the fundus A boggy, high fundus deviated to the right strongly suggests bladder distention displacing the uterus, which increases risk of postpartum hemorrhage from uterine atony. The priority nursing intervention is to assist the client to void (or catheterize if unable) to allow the uterus to contract and return to midline. Fundal massage can be used for uterine atony, but when deviation/high position indicates a full bladder, correcting bladder distention is most appropriate first. After voiding, reassess fundal tone and position and monitor bleeding.
Category reason: This is a postpartum patient-care situation requiring nursing judgment to prevent a complication (postpartum hemorrhage) by addressing a likely cause (bladder distention) and reassessing, which fits NCLEX Reduction of Risk Potential—Potential for Complications.

Question 13

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for fluid volume deficit?

Accepted Answer

Answer reason: The client with a colostomy. A colostomy can lead to increased fluid (and electrolyte) losses through the ostomy output, especially if output is high, placing the client at risk for fluid volume deficit. In contrast, heart failure and decreased kidney function more commonly predispose to fluid volume excess due to impaired pumping/renal excretion. Cirrhosis is associated with third-spacing and edema/ascites (apparent volume overload) rather than straightforward intravascular fluid loss.
Category reason: This item tests nursing risk recognition and planning of care by identifying which condition most predisposes a patient to a complication (dehydration/fluid volume deficit), aligning with monitoring for and preventing potential complications.

Question 14

A NURSE IS CARING FOR A CLIENT IMMEDIATELY AFTER A THORACENTESIS. WHICH OF THE FOLLOWING FINDINGS REQUIRES THE NURSE’S IMMEDIATE INTERVENTION?

Accepted Answer

Answer reason: The client’s oxygen saturation drops from 96% to 88% A significant drop in SpO2 immediately after thoracentesis can indicate an acute complication such as pneumothorax, re-expansion pulmonary edema, or worsening ventilation/perfusion mismatch. This is an urgent change in oxygenation requiring prompt assessment (respiratory status, breath sounds, vital signs) and rapid intervention (supplemental oxygen and notifying the provider/activating rapid response as indicated). Mild puncture-site discomfort and a small amount of serosanguinous drainage are expected post-procedure findings. Positioning may vary by policy, but it is not as immediately life-threatening as acute desaturation.
Category reason: This item tests post-procedure nursing surveillance and rapid recognition/response to complications (e.g., pneumothorax) after a therapeutic procedure, which aligns with Reduction of Risk Potential—Potential for Complications.

Question 15

A patient is admitted with Guillain-Barré syndrome. What is the priority nursing action?

Accepted Answer

Answer reason: Monitor respiratory rate and oxygen saturation Guillain-Barré syndrome can rapidly progress to diaphragmatic and intercostal muscle weakness, leading to respiratory failure, which is the most immediate life-threatening complication. Continuous assessment of respiratory status (rate, SpO2, and closely watching for declining ventilatory effort) supports early recognition and timely escalation (e.g., ABGs, vital capacity monitoring, airway support). IVIG is an important treatment but is not the first nursing priority over airway/breathing surveillance. DVT prevention and physical therapy are important but secondary to maintaining adequate ventilation and oxygenation.
Category reason: This is a prioritization question focused on a nursing action to prevent a life-threatening complication (respiratory failure) in a hospitalized patient, which aligns with NCLEX Physiological Integrity and monitoring for potential complications.

Question 16

A client with a chest tube to water seal shows continuous bubbling in the water-seal chamber. What is the best initial action?

Accepted Answer

Answer reason: Briefly clamp near the chest and then the drainage system to locate the air leak; secure connections Continuous bubbling in the water-seal chamber indicates an air leak somewhere in the chest tube system. The safest best initial step is to systematically identify whether the leak is from the patient (near the insertion site) or from the drainage tubing/system by briefly clamping in sequence and then tightening/repairing loose connections. Adding water to the suction-control chamber or increasing wall suction does not address the source of the leak. Removing the dressing is not the first action and can risk disrupting the chest tube seal if the issue is actually in the tubing connections.
Category reason: This question tests nursing assessment and immediate troubleshooting to prevent complications from a chest tube system malfunction (air leak), which fits Reduction of Risk Potential—Potential for Complications.

Question 17

A client who is receiving a blood transfusion rings the call bell for the nurse. When entering the room, the nurse notes that the client is flushed, dyspneic, and complaining of generalized itching. How should the nurse correctly interpret these findings?

Accepted Answer

Answer reason: D. Transfusion reaction. Flushing, dyspnea, and generalized itching during a blood transfusion are classic features of an acute allergic transfusion reaction (hypersensitivity), which can range from urticaria/pruritus to anaphylaxis with respiratory compromise. These findings fit a transfusion reaction more directly than fluid overload (typically hypertension, crackles, JVD) or hypovolemic shock (hypotension, tachycardia, cool clammy skin). Bacteremia/septic reaction can occur but more commonly presents with fever, chills, and hypotension rather than prominent itching.
Category reason: This question tests nursing recognition of a potential complication during blood product administration and the correct clinical interpretation of acute signs and symptoms, which aligns with monitoring for complications under Reduction of Risk Potential.

Question 18

The priority nursing goals of proper wound care include all of the following EXCEPT:

Accepted Answer

Answer reason: Promotion of dehiscence Proper wound care aims to prevent complications such as infection and wound separation, not promote them. Dehiscence is a complication where a wound reopens, increasing risk for infection and impaired healing. Measuring drainage helps monitor for bleeding, infection, or poor healing, and promoting comfort is a standard nursing goal for wound management.
Category reason: This question tests nursing goals/interventions to reduce postoperative/wound-care complications (e.g., infection, dehiscence), which fits Reduction of Risk Potential—Potential for Complications.

Question 19

A client receiving magnesium sulfate for severe preeclampsia becomes lethargic with a respiratory rate of 10/min and absent deep tendon reflexes. What is the nurse’s priority action?

Accepted Answer

Answer reason: Turn off the magnesium sulfate infusion Respiratory depression (RR 10/min) and absent deep tendon reflexes are classic signs of magnesium toxicity, a life-threatening complication of magnesium sulfate therapy. The immediate priority is to stop the infusion to prevent further magnesium accumulation and worsening respiratory failure. After stopping the infusion, the nurse should support airway/breathing (e.g., oxygen) and notify the provider; the antidote (calcium gluconate) may be required per orders.
Category reason: This item tests nursing recognition and immediate intervention for a medication-related maternal complication (magnesium toxicity) to prevent further harm, which aligns with monitoring for and responding to potential complications.

Question 20

The client with spinal cord injury is prone to experiencing autonomic dysreflexia. The least appropriate measure to minimize the risk of autonomic dysreflexia is which action?

Accepted Answer

Answer reason: Limiting bladder catheterization to once every 12 hours. Autonomic dysreflexia is commonly triggered by bladder distention/urinary retention in clients with spinal cord injury (especially at/above T6). Limiting catheterization to every 12 hours increases the chance of bladder overfilling, making this the least appropriate preventive action. In contrast, bowel program adherence, preventing skin/linen irritation, and avoiding pressure reduce noxious stimuli below the injury level that can precipitate dysreflexia.
Category reason: This item tests nursing prevention of a life-threatening complication (autonomic dysreflexia) by identifying an unsafe care practice that increases triggering stimuli, which aligns with monitoring/preventing potential complications.

Question 21

Which assessment finding could indicate hemorrhage in the postpartum patient?

Accepted Answer

Answer reason: Elevated pulse rate Tachycardia is an early compensatory sign of hypovolemia and can be a key indicator of postpartum hemorrhage, sometimes appearing before hypotension. A firm, midline fundus suggests adequate uterine tone, making uterine atony less likely. Saturating one pad in an hour can be concerning depending on pad size and clinical context, but the most reliable systemic sign listed that could indicate hemorrhage is an elevated pulse rate. Elevated blood pressure is not expected with hemorrhage; blood pressure typically falls late as compensation fails.
Category reason: This item tests nursing recognition of a postpartum complication (hemorrhage) through assessment findings and early clinical signs of hypovolemia, which fits NCLEX focus on monitoring for potential complications.

Question 22

A patient with severe pancreatitis develops shallow respirations and confusion. Labs show calcium 6. mg/dL. What should the nurse do first?

Accepted Answer

Answer reason: Place on cardiac monitor Severe hypocalcemia (Ca ~6 mg/dL) can precipitate dangerous dysrhythmias (e.g., prolonged QT, torsades) and the patient already has concerning symptoms (confusion, shallow respirations). The priority first action is to initiate continuous cardiac monitoring to rapidly detect and respond to arrhythmias while urgent treatment is arranged. Administering IV calcium is appropriate, but monitoring is the immediate safety step because it addresses the highest-risk complication (life-threatening rhythm changes) and supports rapid escalation of care.
Category reason: This is a patient-care prioritization question asking the nurse’s first action to prevent/identify complications of an abnormal lab value (hypocalcemia), which fits NCLEX Reduction of Risk Potential—Potential for Complications.

Question 23

True or False A patient with a chest tube should be placed in Trendelenburg position.?

Accepted Answer

Answer reason: False Trendelenburg positioning is not routine for patients with chest tubes and can worsen ventilation by reducing lung expansion and increasing work of breathing. Standard positioning is typically semi-Fowler’s or upright to promote lung re-expansion and facilitate drainage. Trendelenburg may be used briefly only for specific procedures (e.g., central line insertion) or certain hemodynamic indications, not as a general chest-tube care recommendation.
Category reason: This item tests safe nursing positioning and prevention of respiratory complications in a patient with a chest tube, which aligns with monitoring for and preventing potential complications.

Question 24

Which symptom most likely represents a complication of a central venous catheter?

Accepted Answer

Answer reason: Fever Fever is a common sign of central line–associated bloodstream infection (CLABSI), a major complication of central venous catheters. A CVC provides direct access to the bloodstream, so bacterial contamination can rapidly cause systemic infection, often presenting with fever and chills. Polyuria, hypertension, and bradycardia are not typical primary indicators of CVC-related complications compared with infection.
Category reason: This item tests recognition of a complication related to a therapeutic procedure/device (central venous catheter) and identifying an associated clinical sign, which aligns with monitoring for potential complications.

Question 25

A patient with a DVT should be encouraged to ambulate frequently.?

Accepted Answer

Answer reason: False In an acute DVT, frequent ambulation may increase the risk of thrombus dislodgement and pulmonary embolism before the clot is stabilized. Initial nursing care typically emphasizes bed rest or limited activity with leg elevation and initiation of anticoagulation. Ambulation is generally resumed once adequately anticoagulated/stable per provider orders and institutional protocol to reduce venous stasis while balancing embolic risk.
Category reason: This item tests nursing actions to prevent a serious complication (pulmonary embolism) in a client with DVT, which fits Reduction of Risk Potential—Potential for Complications.

Question 26

A nurse is caring for a client who has just undergone a thyroidectomy. Which of the following findings should the nurse report immediately?

Accepted Answer

Answer reason: Tingling around the mouth Perioral tingling after thyroidectomy is an early sign of hypocalcemia, most commonly due to inadvertent removal/trauma of the parathyroid glands leading to low calcium. Hypocalcemia can rapidly progress to tetany, laryngospasm, stridor, and seizures, making it a time-sensitive complication requiring immediate reporting and intervention (e.g., calcium assessment/replacement). Mild neck pain and some hoarseness can be expected post-op, while dysphagia can occur from edema but is less specific than classic hypocalcemia symptoms.
Category reason: This is a post-operative nursing assessment question focused on recognizing and promptly reporting a life-threatening complication after thyroidectomy, which fits NCLEX patient-care judgment under Potential for Complications.

Question 27

A patient with a chest tube has continuous bubbling in the water seal chamber. What should the nurse do first?

Accepted Answer

Answer reason: CHECK FOR AIR LEAK Continuous bubbling in the water-seal chamber indicates an air leak (from the patient, tubing connections, or the drainage system) rather than the expected intermittent tidaling. The priority first action is to assess and troubleshoot the system—inspect connections and the tubing/drainage unit to locate the source of the leak. Clamping can be dangerous (risk of tension pneumothorax) and is not a first-line nursing action unless briefly ordered for troubleshooting per policy. Milking/stripping tubing is generally avoided because it can create excessive negative pressure and tissue trauma.
Category reason: This is a nursing management question focused on recognizing an abnormal chest tube finding and taking the safest immediate action to prevent complications, which fits Potential for Complications.

Question 28

True or False: A patient with a tracheostomy should always have humidified oxygen.?

Accepted Answer

Answer reason: True A tracheostomy bypasses the upper airway, which normally warms and humidifies inspired air. Without added humidification, secretions can become thick and dry, increasing the risk of mucus plugging and airway obstruction. Providing humidified oxygen/air (as ordered and appropriate to the delivery system) helps maintain secretion moisture and supports airway patency and respiratory comfort.
Category reason: This item tests nursing care to prevent respiratory complications in a client with an artificial airway (tracheostomy), which fits Reduction of Risk Potential—Potential for Complications.

Question 29

Daya's child is scheduled for surgery due to myelomeningocele; the primary reason for surgical repair is which of the following?

Accepted Answer

Answer reason: To reduce the risk of infection The exposed neural tissue and meninges in myelomeningocele create a direct pathway for bacterial contamination, making meningitis and other infections a major immediate risk. Early surgical closure primarily aims to cover and protect the defect to prevent infection and further trauma. While hydrocephalus is common and may require shunting, closure does not reliably prevent it. Surgery also does not reverse established neurologic deficits; it mainly prevents worsening and complications.
Category reason: This question tests nursing understanding of the main goal of a surgical intervention and the complication it is intended to prevent (infection risk) in a pediatric condition, aligning with monitoring/preventing potential complications.

Question 30

A nurse is caring for a newborn that is 4 hours old. The mother’s blood type is O+, and the newborn’s blood type is B+. The baby’s COOMBS test is positive. The nurse should assess the newborn for?

Accepted Answer

Answer reason: Hyperbilirubinemia A positive direct Coombs test in this setting indicates immune-mediated hemolysis due to ABO incompatibility (type O mother with a type B infant). Hemolysis increases breakdown of red blood cells, leading to elevated unconjugated bilirubin and early jaundice risk. The priority assessment is for rising bilirubin levels and clinical jaundice because untreated severe hyperbilirubinemia can progress to acute bilirubin encephalopathy/kernicterus. The other options are not the expected primary complication of Coombs-positive hemolytic disease.
Category reason: This is a patient-care decision about monitoring for a predictable newborn complication (hemolysis leading to jaundice) rather than testing standalone physiology, so it fits NCLEX nursing judgment under monitoring for potential complications.

Question 31

True or False A patient with a history of deep vein thrombosis (DVT) should avoid prolonged immobility.?

Accepted Answer

Answer reason: True Immobility promotes venous stasis, which increases the risk of clot formation and recurrence of venous thromboembolism in patients with prior DVT. Encouraging regular ambulation, leg exercises, and minimizing long periods of sitting are key preventive measures. This also reduces the chance of clot propagation and pulmonary embolism, a life-threatening complication.
Category reason: This item tests nursing prevention of a serious complication (recurrent DVT/PE) through risk-reduction behaviors (avoiding immobility), which fits Potential for Complications.

Question 32

A spica cast was put on Baby Betty after an unfortunate incident to immobilize her hips and thighs; which of the following is the priority nursing action immediately after application?

Accepted Answer

Answer reason: Perform neurovascular checks. New cast application can compromise circulation and nerve function due to swelling and tightness, creating risk for acute neurovascular impairment and compartment syndrome. Immediate assessment of color, temperature, capillary refill, pulses, movement, sensation, and pain detects early deterioration and prompts urgent intervention to prevent tissue ischemia. Other measures (keeping the cast clean/dry, perineal protection, elevation) are important but do not supersede early detection of a limb-threatening complication right after casting.
Category reason: This item tests a priority nursing assessment/action to prevent and detect complications immediately after a therapeutic procedure (cast application), which aligns with monitoring for potential complications.

Question 33

What is the primary purpose of preoperative assessment in surgical care?

Accepted Answer

Answer reason: To identify and reduce surgical risks Preoperative assessment focuses on finding patient-specific factors that increase perioperative morbidity (e.g., uncontrolled comorbidities, medication/anticoagulant use, allergies, airway risk, infection risk). Identifying these issues allows the team to optimize the patient and plan anesthesia and perioperative monitoring to prevent avoidable complications. Scheduling, equipment checks, and general teaching may occur, but they are not the primary goal of the assessment itself. The central purpose is risk stratification and mitigation to improve surgical outcomes.
Category reason: This question asks about the nursing purpose of preoperative assessment to prevent perioperative complications, which aligns with reducing risk potential through identifying and managing potential complications.

Question 34

A nurse must reposition a patient who just had spinal anesthesia. What is the safest technique?

Accepted Answer

Answer reason: After spinal anesthesia, maintaining a flat position initially helps reduce risk of complications related to cerebrospinal fluid leakage and post-dural puncture headache. It also supports hemodynamic stability while sympathetic blockade may persist, decreasing the chance of orthostatic hypotension and falls. Trendelenburg or immediate high head elevation can worsen cephalad spread or destabilize blood pressure. Early ambulation increases fall risk until motor and sensory function are fully returned.
Category reason: This question centers on safe nursing positioning and monitoring to prevent post-spinal anesthesia complications, which is a patient-care risk-reduction decision rather than basic science recall.

Question 35

A nurse teaches a client with hypoglycemia unawareness to:

Accepted Answer

Answer reason: A. Check blood sugar regularly even if asymptomatic Hypoglycemia unawareness means the client may not experience early adrenergic warning signs, increasing risk for sudden severe hypoglycemia. Regular capillary glucose monitoring helps detect low levels early so the client can treat promptly and prevent seizures, loss of consciousness, or injury. Stopping insulin or taking it without checking glucose is unsafe, and increasing bedtime insulin raises the risk of nocturnal hypoglycemia.
Category reason: This item tests a nursing teaching/safety intervention to prevent a complication (severe hypoglycemia) in a client with impaired symptom awareness, which aligns with monitoring and prevention of complications.

Question 36

Which patient statement suggests proper understanding of post-operative care after rotator cuff repair?

Accepted Answer

Answer reason: After rotator cuff repair, protecting the tendon repair is essential to prevent re-tear, so lifting and other resisted shoulder activities are restricted during early healing. The sling is typically worn as prescribed, including during sleep, to maintain immobilization and reduce strain on the repair. Driving is usually restricted until the client is off sedating analgesics and has adequate control/ROM, and overhead exercises are not started immediately unless specifically ordered in a staged rehabilitation plan.
Category reason: This item tests post-operative patient teaching to prevent complications (e.g., re-injury/re-tear) after an orthopedic procedure, which aligns with monitoring and preventing potential complications.

Question 37

A nurse is teaching cast care to a pediatric client. What is the most age-appropriate method to prevent itching under the cast?

Accepted Answer

Answer reason: Scratching under a cast or inserting objects/materials can break the skin, introduce bacteria, and lead to pressure injury or infection that cannot be visualized easily. Tapping lightly (or using other safe external comfort measures like cool air from a hair dryer on a cool setting) can reduce the sensation of itching without compromising skin integrity. Removing the cast is not a client-controlled action and would disrupt immobilization, increasing the risk of complications and delaying healing.
Category reason: This question tests safe patient-care teaching to prevent cast-related skin breakdown and infection, focusing on preventing complications of an immobilization device.

Question 38

A client had a hip replacement. Which position should the nurse avoid during the first 48 hours post-op?

Accepted Answer

Answer reason: Hip precautions after total hip arthroplasty are aimed at preventing prosthetic hip dislocation, especially early in recovery when soft tissues are healing. Excessive hip flexion beyond 90 degrees increases posterior dislocation risk (commonly with sitting in low chairs or bending at the waist). Abduction positioning and use of an abduction pillow help maintain safe alignment and reduce dislocation risk. A raised toilet seat decreases the need for deep hip flexion during toileting and supports adherence to precautions.
Category reason: This item tests nursing management to prevent a postoperative complication (hip dislocation) by avoiding unsafe positioning after hip replacement, which aligns with monitoring/preventing complications.

Question 39

A patient is scheduled for arthroscopy of the knee. What preoperative teaching is most appropriate?

Accepted Answer

Answer reason: e." Post-arthroscopy, mild swelling is a common expected outcome due to intra-articular irrigation and soft-tissue manipulation, and patients should be prepared for it and taught basic management (elevation, ice, activity as directed). The other statements are misleading: arthroscopy is typically a short procedure and often uses regional or brief general anesthesia, prolonged non–weight-bearing for months is not typical for routine cases, and describing recovery as “highly painful” is inaccurate and increases anxiety. Teaching should set realistic expectations while reinforcing what findings are normal versus when to seek care (e.g., severe pain, fever, increasing redness, drainage).
Category reason: This item tests appropriate preoperative patient teaching about expected postoperative findings and recognizing typical versus concerning outcomes, which aligns with nursing risk reduction and preventing complications after a procedure.

Question 40

The nurse is caring for a client with a cervical spinal cord injury. What equipment must be at the bedside?

Accepted Answer

Answer reason: High cervical spinal cord injuries can impair diaphragmatic/intercostal function and weaken the cough and gag reflexes, greatly increasing the risk of retained secretions and airway obstruction. Immediate access to suction allows rapid clearance of secretions to maintain airway patency and prevent hypoxia and atelectasis. Other equipment may be helpful for monitoring or breathing exercises, but it does not address the urgent bedside need for airway clearance if the client cannot effectively cough.
Category reason: This question tests nursing preparedness to prevent and respond to respiratory complications in a high-risk patient (cervical spinal cord injury), which aligns with monitoring and preventing potential complications.

Question 41

A patient is recovering from a total hip replacement. Which action by the nurse is appropriate?

Accepted Answer

Answer reason: This maintains hip abduction and helps prevent hip dislocation after a total hip arthroplasty by avoiding adduction and internal rotation. Crossing the legs increases adduction and is a classic movement restriction after surgery. Elevating the leg above the heart is not a routine hip-replacement precaution and may not address the primary postoperative risk. High Fowler’s can increase hip flexion beyond the recommended limit (often >90°), which can also raise dislocation risk.
Category reason: This question tests postoperative nursing interventions to prevent complications (hip dislocation) after total hip replacement, which is a patient-safety/potential complication focus.

Question 42

After spinal surgery, which finding should the nurse report immediately?

Accepted Answer

Answer reason: Spinal surgery and spinal/epidural anesthesia can impair bladder innervation and lead to acute urinary retention, which risks bladder overdistention, overflow incontinence, and potential kidney injury if not promptly addressed. New or worsening inability to void can also signal neurologic compromise that requires timely evaluation. By contrast, expected postoperative findings include localized incisional pain, small amounts of dressing drainage, and transiently decreased bowel sounds from anesthesia/opioids unless severe or progressive.
Category reason: This is a postoperative nursing surveillance question focused on recognizing and reporting a potential complication after surgery, which fits Reduction of Risk Potential—Potential for Complications.

Question 43

A postoperative client reports feeling something “pop” in their abdominal wound followed by increased drainage. What should the nurse do first?

Accepted Answer

Answer reason: This presentation suggests wound dehiscence/evisceration risk, which is an acute postoperative complication requiring immediate protection of exposed tissues and prevention of drying and infection. The priority action is to cover the area with a sterile dressing moistened with normal saline and maintain the client in a safe position (typically low-Fowler’s with knees flexed) to reduce tension on the incision. After stabilizing the wound, the nurse should promptly notify the surgeon and continue monitoring for signs of shock or further separation. Re-inserting staples is outside nursing scope and documentation is not the first priority in an emergent complication.
Category reason: This item tests the nurse’s immediate action to prevent deterioration from a postoperative wound complication (dehiscence/evisceration), which aligns with monitoring and intervening for potential complications.

Question 44

Which complication is a nurse most concerned about in a lung cancer patient with bone metastases?

Accepted Answer

Answer reason: Bone metastases can involve the vertebrae and lead to epidural tumor growth, causing acute spinal cord compression. This is a time-sensitive oncologic emergency because delayed recognition can result in irreversible neurologic deficits such as weakness, sensory loss, and bowel/bladder dysfunction. Nursing vigilance for new back pain, gait changes, or urinary retention is crucial to prompt rapid imaging and initiation of corticosteroids and definitive therapy. The other options are less directly associated with bone metastases and are typically not the most immediate, high-risk complication in this context.
Category reason: This item tests nursing recognition and prioritization of a high-risk complication (oncologic emergency) requiring rapid escalation, which aligns with monitoring for and preventing complications under Reduction of Risk Potential.

Question 45

A client in skeletal traction reports severe muscle spasms. What is the nurse’s priority action?

Accepted Answer

Answer reason: Severe spasms in skeletal traction often indicate a complication such as malalignment, loss of effective traction, or excessive traction causing muscle fatigue. The priority is to assess the traction setup (line of pull, body alignment, and that weights are hanging freely) to identify and correct the underlying cause and prevent neurovascular compromise or impaired fracture alignment. Sedation addresses symptoms but can mask worsening issues and does not correct mechanical problems. Massage may be contraindicated around injured tissues and also delays correction of the traction problem.
Category reason: This is a patient-care priority question about nursing assessment and preventing complications associated with skeletal traction, which aligns with monitoring for complications in Reduction of Risk Potential.

Question 46

A nurse is caring for a client post-lumbar puncture who reports a severe headache. What is the most appropriate position?

Accepted Answer

Answer reason: A severe post–lumbar puncture headache is most consistent with cerebrospinal fluid leakage causing intracranial hypotension, which is worsened by upright posture. Keeping the client flat helps reduce traction on pain-sensitive structures and can decrease CSF leakage at the puncture site. High Fowler’s or elevating the head typically aggravates symptoms; prone head-down is not standard management and may be uncomfortable or unsafe.
Category reason: This question tests the nurse’s positioning intervention to reduce a known post-procedure complication (post-lumbar puncture headache), which is nursing care aimed at preventing/worsening complications.

Question 47

The nurse is positioning a patient post-craniotomy on the right side (supratentorial). Which position is most appropriate?

Accepted Answer

Answer reason: B. Left lateral with HOB elevated 30° Elevating the head of bed about 30 degrees promotes venous drainage and helps reduce intracranial pressure while maintaining adequate cerebral perfusion. After a supratentorial craniotomy, positioning on the nonoperative side helps avoid pressure on the operative site and can reduce the risk of impaired venous outflow. Keeping the head flat can increase intracranial venous congestion, and extreme elevation (90°) may compromise cerebral perfusion. Prone positioning with head rotation can obstruct jugular venous return and increase aspiration and airway risks in the immediate postoperative period.
Category reason: This is a nursing care decision about postoperative positioning to prevent neurologic complications (e.g., increased ICP, impaired cerebral perfusion) after craniotomy, which fits Reduction of Risk Potential—Potential for Complications.

Question 48

Meconium-Stained Amniotic Fluid A nurse notes meconium-stained amniotic fluid during labor. What is the priority intervention?

Accepted Answer

Answer reason: Meconium-stained fluid signals possible fetal stress and creates a risk for meconium aspiration at delivery, which can cause significant respiratory compromise. The safest immediate nursing priority is to anticipate neonatal airway/respiratory support by preparing equipment and personnel for prompt clearing and resuscitation as needed. Amnioinfusion may be used in select cases but is not the first priority over readiness for neonatal stabilization. Antibiotics and urging faster pushing do not address the acute aspiration/airway risk.
Category reason: This is a labor-and-delivery patient-care question focused on preventing and responding to a potential neonatal complication (meconium aspiration), requiring nursing prioritization and preparedness rather than foundational science knowledge.

Question 49

A nurse teaches a client about preventing complications of diabetic foot ulcers. Which statement needs correction?

Accepted Answer

Answer reason: r." Using sharp instruments on the feet is unsafe for clients with diabetes because neuropathy and reduced perfusion increase the risk of unrecognized injury, infection, and poor wound healing. Callus trimming should be performed by a podiatrist or trained clinician, and clients should use protective measures like proper footwear and moisturizing (avoiding between toes). Daily inspection, avoiding barefoot walking, and keeping feet clean and dry are appropriate preventive strategies to reduce ulcer risk.
Category reason: This item tests nursing teaching to prevent foot ulcer complications and reduce risk of injury/infection in diabetes, which aligns with monitoring and preventing potential complications.

Question 50

A client with diabetes insipidus is on desmopressin. Which finding indicates the dose may be too high?

Accepted Answer

Answer reason: Desmopressin is an ADH analog; an excessive dose can cause water retention and dilutional hyponatremia. Neurologic symptoms such as headache and confusion are classic early signs of hyponatremia and water intoxication. In contrast, dry mucous membranes and polyuria suggest inadequate ADH effect and ongoing dehydration. A normal blood pressure does not specifically indicate over-replacement.
Category reason: This item tests recognition of a medication-related complication (water intoxication/hyponatremia) and the nurse’s need to identify an adverse/overdose finding, which fits monitoring for potential complications.

Train with a large NCLEX question bank and jump into a full exam-style simulator

Potential for Complications NCLEX Practice Test

Continue Learning