Question 1

A nurse is caring for a client post-thyroidectomy. The client develops numbness around the mouth and tingling in fingers. What is the priority action?

Accepted Answer

Answer reason: Perioral numbness and tingling after thyroidectomy are classic early signs of hypocalcemia due to inadvertent removal or stunning of the parathyroid glands. This can rapidly progress to tetany, laryngospasm, and seizures, so confirming calcium status is a priority to guide prompt treatment (e.g., calcium replacement). Reassurance alone delays care, and oxygen or head-of-bed elevation do not address the underlying electrolyte complication driving the neuromuscular irritability. Early recognition and intervention reduce risk of airway compromise and other serious sequelae.
Category reason: This is a post-operative nursing priority focused on recognizing and responding to a likely complication (hypocalcemia) after thyroidectomy, which best fits monitoring for and preventing complications under Reduction of Risk Potential.

Question 2

A client is being discharged after an MI. Which instruction should the nurse emphasize?

Accepted Answer

Answer reason: s." Rapid weight gain after an MI can indicate fluid retention from worsening heart failure, which requires prompt evaluation and possible adjustment of diuretics or other therapy. Teaching the patient to monitor daily weight and report sudden increases helps detect decompensation early and prevents complications such as pulmonary edema. The other options are unsafe because recovery includes gradual activity, medications should be taken as prescribed (not PRN for symptoms), and smoking cessation should be permanent.
Category reason: This question focuses on discharge teaching to prevent post-MI complications by recognizing early warning signs (rapid weight gain), which aligns with monitoring and reducing risk potential for complications.

Question 3

A client has a radial artery catheter for continuous BP monitoring. The nurse finds the hand pale and cool. What is the priority?

Accepted Answer

Answer reason: Pallor and coolness distal to a radial arterial catheter suggests decreased perfusion from arterial spasm, thrombus, or occlusion, which can rapidly threaten tissue viability. This is an acute complication that requires immediate escalation for prompt evaluation and potential catheter removal or other interventions to restore circulation. Repositioning or checking equipment may be done quickly, but they must not delay reporting signs of compromised arterial blood flow. Allen’s test is a pre-insertion assessment of collateral circulation and is not the appropriate response once ischemic signs are present.
Category reason: This item centers on recognizing and responding to a serious complication of an invasive arterial line and taking appropriate nursing action to prevent harm, which aligns with monitoring for and managing potential complications.

Question 4

A client had surgery to remove a prolactinoma (pituitary tumor). Which nursing intervention is appropriate?

Accepted Answer

Answer reason: After pituitary surgery (often transsphenoidal), the priority is reducing intracranial pressure and promoting venous drainage to decrease bleeding and CSF leak risk. Keeping the head midline with the head of bed elevated supports this and helps minimize pressure on the surgical site. Actions that increase intrathoracic/intracranial pressure (like Valsalva) are avoided, and vigorous coughing can also raise intracranial pressure and disrupt the repair.
Category reason: This question tests a post-operative nursing intervention aimed at preventing complications (e.g., bleeding, increased intracranial pressure, CSF leak) after pituitary surgery, which fits NCLEX-level patient care and risk reduction decision-making.

Question 5

A patient develops signs of air embolism during IV catheter insertion. What should the nurse do immediately?

Accepted Answer

Answer reason: This maneuver helps trap air in the right atrium/ventricle and prevents it from moving into the pulmonary artery, reducing the risk of cardiovascular collapse. It is an immediate complication-management action for suspected venous air embolism during line insertion. The nurse should also stop the source of air entry (clamp/occlude the catheter site) and give high-flow oxygen, but the first priority positioning is to limit air migration.
Category reason: This question tests immediate nursing action to manage a potentially life-threatening IV therapy complication (air embolism), which aligns with preventing and responding to complications under Reduction of Risk Potential.

Question 6

The nurse is caring for a patient in a cast who develops pain unrelieved by medication, pallor, and weak pulse. What is the priority action?

Accepted Answer

Answer reason: C. Notify the physician immediately These findings suggest acute neurovascular compromise/compartment syndrome from a tight cast, which can rapidly progress to limb ischemia and tissue necrosis. Pain out of proportion and not relieved by analgesics with pallor and diminished pulses is an emergency requiring urgent provider evaluation for cast bivalving or fasciotomy. Elevation or icing may be supportive but must not delay definitive treatment when perfusion is threatened. Reassurance is unsafe because it minimizes a potentially limb-threatening complication.
Category reason: This question tests recognition of a serious cast-related complication and the nurse’s priority escalation to prevent harm, which aligns with monitoring for and responding to potential complications.

Question 7

A client at 9 weeks gestation with molar pregnancy has a serum hCG of 150,000. what is the nurse’s priority? enlarged uterus. what is he nurse’s priority?

Accepted Answer

Answer reason: B. Prepare for uterine evacuation and monitor for bleeding A molar pregnancy produces markedly elevated hCG and uterine enlargement and can cause significant vaginal bleeding due to abnormal trophoblastic proliferation. The immediate priority is to treat the condition with prompt uterine evacuation and closely monitor for hemorrhage and related instability. Methotrexate is not first-line for initial management unless there is persistent gestational trophoblastic neoplasia after evacuation. Reassurance or iron supplementation does not address the urgent risk of acute bleeding and other complications.
Category reason: This is a nursing-priority question focused on recognizing a high-risk obstetric complication and implementing immediate, safety-focused interventions to prevent hemorrhage and monitor for complications, aligning with Potential for Complications.

Question 8

What is the priority nursing action after a client returns from cardiac catheterization?

Accepted Answer

Answer reason: Post–cardiac catheterization, the highest immediate risk is compromised distal perfusion from arterial obstruction, vasospasm, or bleeding/hematoma at the access site. Frequent assessment of distal pulses helps detect acute limb ischemia early so rapid interventions (e.g., provider notification, pressure management, reversal strategies) can occur. Encouraging fluids is important for contrast clearance but is not as time-critical as neurovascular checks. Ambulation and routine dressing changes are delayed until hemostasis and circulation are clearly stable per protocol.
Category reason: This question tests a priority nursing action aimed at early detection of post-procedure vascular complications, which fits Potential for Complications under Reduction of Risk Potential.

Question 9

A nurse receives a post-op thyroidectomy patient. Which item is most important to keep at the bedside?

Accepted Answer

Answer reason: Post-thyroidectomy patients are at risk for acute airway compromise from laryngeal edema, hematoma formation, or laryngeal nerve injury, which can rapidly progress to obstruction. Having emergency airway equipment immediately available allows prompt intervention if stridor or respiratory distress occurs. While suction and spirometry are helpful, they do not address the highest-risk, time-critical complication of sudden loss of airway patency.
Category reason: This question tests nursing preparedness for a high-risk postoperative complication (airway obstruction) and the priority bedside equipment to prevent harm, which aligns with monitoring and preventing complications.

Question 10

A newborn of a diabetic mother is found to be jittery. What should the nurse do?

Accepted Answer

Answer reason: Newborns of diabetic mothers are at high risk for neonatal hypoglycemia due to fetal hyperinsulinemia after separation from maternal glucose supply. Jitteriness is a classic sign of hypoglycemia and should be treated as a potential complication requiring immediate assessment and confirmation. Checking a bedside glucose allows rapid identification and timely intervention (e.g., feeding or IV dextrose) to prevent seizures and neurologic injury. Comfort measures alone could delay recognition of a reversible, urgent cause.
Category reason: This is a patient-care decision requiring nursing assessment and action to identify and prevent a newborn complication (hypoglycemia), aligning with NCLEX Reduction of Risk Potential.

Question 11

A client in second stage pushing for 2 hours (epidural in place) has fetal head at +2, FHR reassuring. What should the nurse anticipate?

Accepted Answer

Answer reason: B. Continue pushing; notify provider for possible assisted delivery After 2 hours of pushing with an epidural, prolonged second stage is possible, but with reassuring fetal status and the head at +2 station (low), vaginal birth is still likely and operative vaginal delivery may be appropriate if descent/arrest occurs. The nurse should anticipate ongoing pushing with provider evaluation rather than emergent cesarean because there is no evidence of fetal compromise. Waiting several more hours is not appropriate at this point, and starting oxytocin is not the primary next step in second-stage management when the patient is already fully dilated and actively pushing.
Category reason: This item tests nursing anticipation and management of a potential intrapartum complication (prolonged second stage) and appropriate next actions/notifications to reduce maternal-fetal risk, fitting Reduction of Risk Potential.

Question 12

The nurse is caring for a patient with aortic valve replacement. Which activity should be avoided postoperatively?

Accepted Answer

Answer reason: After valve replacement, patients are commonly anticoagulated, which increases bleeding risk from minor mucosal trauma. Vigorous tooth brushing can cause gingival bleeding and may be difficult to control when anticoagulated. In contrast, incentive spirometry and deep breathing reduce atelectasis, and assisted ambulation helps prevent complications such as venous thromboembolism and deconditioning. Therefore the safest choice to avoid is the activity most likely to provoke bleeding.
Category reason: This is a postoperative nursing management/safety question focused on preventing complications (especially bleeding) after a cardiovascular surgical procedure, which aligns with NCLEX Reduction of Risk Potential.

Question 13

A child who has just returned from surgery in a hip spica cast is being assessed by the nurse. Which is the priority outcome?

Accepted Answer

Answer reason: Neurovascular compromise is the most urgent early complication after cast application because postoperative swelling can cause the cast to constrict tissue like a tourniquet. Impaired perfusion can rapidly progress to ischemia and compartment syndrome, risking permanent nerve/muscle damage. Therefore the priority outcome focuses on maintaining adequate circulation (e.g., warm skin, normal color, capillary refill, palpable pulses, intact sensation/movement).
Category reason: This question tests nursing prioritization and monitoring for immediate postoperative complications (neurovascular/circulatory status) in a child with a cast, which aligns with NCLEX risk reduction and complication prevention.

Question 14

While caring for a child with meningococcal meningitis the nurse should observe for?

Accepted Answer

Answer reason: This finding suggests meningococcemia with petechiae/purpura and can rapidly progress to septic shock, DIC, and adrenal hemorrhage (Waterhouse-Friderichsen syndrome). Early recognition is a high-priority nursing assessment because the rash may be the first visible sign of life-threatening systemic involvement. Headache can occur with meningitis but is less specific and less predictive of rapid deterioration than a purpuric rash. Dysphagia and ataxia are not classic hallmark findings for meningococcal meningitis compared with the characteristic purpuric rash.
Category reason: The question asks what the nurse should observe for while caring for a child, focusing on clinical assessment to detect serious complications (meningococcemia/sepsis), which aligns with nursing surveillance and risk reduction.

Question 15

The home health nurse is caring for an 85-year-old client. It would require immediate follow-up if the client is reporting?

Accepted Answer

Answer reason: A painful, red area over a pressure point in an older adult suggests an evolving pressure injury, which can progress quickly to skin breakdown, infection, and sepsis if not addressed promptly. Immediate assessment is needed to determine staging, contributing immobility/moisture, and to implement offloading, turning schedules, skin protection, and wound care. The other findings can be important but are generally less time-critical than impending tissue necrosis and infection risk.
Category reason: This is a patient-care judgment question focused on which symptom requires urgent nursing follow-up to prevent a serious complication (pressure injury/infection), fitting NCLEX Reduction of Risk Potential—Potential for Complications.

Question 16

To assess the kidney function of a patient with an indwelling urinary (Foley) catheter, the nurse measures his hourly urine output. She should notify the physician if the urine output is?

Accepted Answer

Answer reason: Urine output below 30 mL/hr suggests inadequate renal perfusion and possible acute kidney injury or hypovolemia. This low output is a common early sign of deterioration that may require prompt assessment of volume status, hemodynamics, and catheter patency. The other options average ≥30 mL/hr (32 mL/hr, 30 mL/hr, and 31.25 mL/hr respectively), which are generally acceptable for an adult unless other concerning findings are present.
Category reason: This is a nursing monitoring and escalation question focused on recognizing a complication risk (oliguria) and when to notify the provider, fitting Reduction of Risk Potential—Potential for Complications.

Question 17

Post-op care after cataract surgery includes—

Accepted Answer

Answer reason: Bending at the waist increases venous pressure and can raise intraocular pressure, which risks wound leakage, hemorrhage, or displacement of the intraocular lens after cataract surgery. Standard postoperative instructions aim to prevent spikes in intraocular pressure by avoiding bending/straining and heavy lifting. The other options either increase risk of trauma/pressure to the operative eye or are not key preventive instructions in the immediate postoperative period.
Category reason: This item tests a postoperative nursing instruction aimed at preventing complications after an eye procedure, which aligns with monitoring/preventing potential complications in the Reduction of Risk Potential domain.

Question 18

A nurse monitors a laboring patient with oxytocin infusion. The fetal heart rate shows late decelerations with minimal variability. What is the priority action?

Accepted Answer

Answer reason: A. Stop oxytocin infusion Late decelerations with minimal variability indicate uteroplacental insufficiency and fetal hypoxemia, often worsened by uterine tachysystole from oxytocin. The most urgent intervention is to remove the provoking cause by discontinuing oxytocin to reduce contraction frequency and improve placental perfusion. After stopping the infusion, intrauterine resuscitation measures (repositioning, IV fluid bolus, oxygen per policy) can be implemented and the provider notified if the pattern persists.
Category reason: This is a labor-and-delivery nursing judgment question requiring immediate intervention to prevent fetal compromise during oxytocin administration, which aligns with monitoring for and responding to potential complications.

Question 19

Which of these is a common post-stroke complication?

Accepted Answer

Answer reason: Post-stroke dysphagia and impaired cough/gag reflex increase the risk of aspirating oral secretions or food into the lungs. This can rapidly lead to pneumonia and is a major, preventable cause of morbidity and mortality after stroke. Early swallow screening, aspiration precautions, and appropriate diet modifications are key nursing interventions to reduce this risk.
Category reason: This question tests recognition of a common complication after a clinical event (stroke) and focuses on anticipating and preventing patient complications, aligning with Potential for Complications under Reduction of Risk Potential.

Question 20

The nurse is reviewing laboratory data for assigned clients. Which laboratory result requires immediate follow-up with the primary healthcare provider (PHCP)?

Accepted Answer

Answer reason: C. Urinalysis positive for leukocytes and nitrites for a client receiving chemotherapy This indicates a likely urinary tract infection, and a client on chemotherapy may be immunosuppressed and at high risk for rapid progression to sepsis. Prompt provider notification is needed for evaluation, urine culture, and timely antimicrobial therapy. The other findings are expected or less urgent in their contexts (amylase elevation with pancreatitis and leukocytosis with an infected wound), and the hyperglycemia listed is elevated but not inherently emergent without signs of DKA/HHS or severe symptoms.
Category reason: This question tests nursing judgment about which lab abnormality signals an urgent complication requiring immediate provider notification and escalation of care, aligning with Reduction of Risk Potential (Potential for Complications).

Question 21

Which of the following should be incladed when teaching a patient about proper foot care?

Accepted Answer

Answer reason: Daily inspection helps detect early skin breakdown, blisters, redness, cracks, ingrown nails, or infection before they progress to ulcers, especially in patients with neuropathy or poor perfusion (e.g., diabetes). Early identification supports prompt intervention and reduces risk of serious complications such as cellulitis or amputation. In contrast, soaking frequently can macerate skin, and heat-based measures (warm compresses) increase burn risk when sensation is impaired; routine massage can also cause tissue injury if circulation is poor.
Category reason: This is a patient-teaching and complication-prevention question focused on nursing guidance to reduce risk of foot injury and subsequent infection/ulceration, which fits Reduction of Risk Potential.

Question 22

Postoperative care for total hip replacement involves avoiding which position?

Accepted Answer

Answer reason: This movement increases the risk of hip dislocation after total hip arthroplasty, especially with a posterior approach, because it drives the femoral head toward an unstable position in the acetabulum. Standard precautions include keeping the legs abducted (often with an abduction pillow) and avoiding crossing the legs. Supine positioning and elevating the head of the bed are generally permitted as long as hip flexion precautions and alignment are maintained.
Category reason: This item tests nursing postoperative positioning to prevent a complication (prosthetic hip dislocation), which is a patient-safety intervention under Reduction of Risk Potential.

Question 23

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 friction, pressure, or irritation over the incision and device pocket during healing and long-term wear. Advising avoidance of microwaves is outdated because modern devices are well shielded and routine microwave use is generally safe. Clients should also keep cell phones at least several inches away and use the ear opposite the device to reduce potential electromagnetic interference. Soaking in a tub is typically avoided until the incision is fully healed to reduce infection risk; showering is usually preferred once permitted by the provider.
Category reason: This item tests patient teaching to prevent complications and reduce risk after implantation of a cardiac device, which aligns with monitoring and prevention of procedure-related complications.

Question 24

A nurse is caring for a patient with suspected spinal cord injury at T6. What complication should the nurse monitor for?

Accepted Answer

Answer reason: Spinal cord injury at or above T6 places the patient at high risk for a massive sympathetic discharge triggered by noxious stimuli below the lesion (commonly bladder distention or bowel impaction). This can cause severe hypertension with reflex bradycardia, headache, flushing/sweating above the injury level, and can lead to stroke or seizures if not treated promptly. Neurogenic shock is more typical in the acute phase (often with injuries at/above T6) but the hallmark complication specifically associated with the T6 level regarding ongoing monitoring is autonomic dysreflexia. Cerebral edema is not a typical direct complication of thoracic spinal cord injury, and DVT risk exists with immobility but is not uniquely linked to the T6 threshold.
Category reason: This item tests nursing monitoring for a life-threatening complication of spinal cord injury and the need for surveillance for associated physiologic changes, fitting NCLEX Reduction of Risk Potential (Potential for Complications).

Question 25

A client with benign prostatic hyperplasia (BPH) is post-operative following transurethral resection of the prostate (TURP) and is now receiving continuous bladder irrigation. Upon assessment, the nurse notes that the output from the urinary catheter has stopped. Which nursing intervention is most appropriate?

Accepted Answer

Answer reason: C. Attempt to dislodge a clot With continuous bladder irrigation after TURP, sudden cessation of catheter output most commonly indicates obstruction from clots or kinking, which can quickly lead to bladder distention and increased bleeding risk. The priority is to restore catheter patency by checking the system and using manual irrigation per protocol to clear the obstruction. Increasing the irrigation rate can worsen bladder overdistention if outflow remains blocked, and reinserting a catheter is not first-line and may traumatize the surgical site. The provider should be notified if patency cannot be restored or if significant bleeding/instability occurs.
Category reason: This item tests immediate nursing intervention to manage a common post-TURP complication (catheter obstruction during continuous bladder irrigation), which is a patient-care safety/complication-prevention decision under Reduction of Risk Potential.

Question 26

A cuff pressure manometer is connected to the endotracheal tube of a patient receiving continuous mechanical ventilation. The cuff pressure reading is 24 torr with a small air leak auscultated during inspiration. Which of the following should be done?

Accepted Answer

Answer reason: A cuff pressure of 24 torr is within the typical safe range (about 20–30 cm H2O) intended to minimize tracheal mucosal ischemia while maintaining an adequate seal. A small inspiratory leak can be acceptable at this pressure, especially if ventilation and oxygenation are adequate, and immediately increasing pressure risks tracheal injury. The safest approach is ongoing monitoring and reassessment for changes in leak, delivered tidal volumes, and signs of inadequate ventilation, intervening only if the leak becomes clinically significant.
Category reason: This question tests nursing management of an intubated, mechanically ventilated patient by balancing airway device parameters to prevent complications (e.g., tracheal injury vs inadequate seal), which fits Reduction of Risk Potential—Potential for Complications.

Question 27

Which nursing action is the priority when administering chelation therapy for a toddler-age client?

Accepted Answer

Answer reason: Chelating agents (e.g., EDTA, dimercaprol, succimer) bind heavy metals and are eliminated primarily via the kidneys, so maintaining and verifying adequate renal clearance is critical to prevent nephrotoxicity. Urine output is an immediate, continuous indicator of renal perfusion and function during therapy and helps identify complications early. While vital signs and education are important, they do not monitor the key elimination pathway and main acute risk of chelation therapy as directly as output assessment in a toddler.
Category reason: This item tests a priority nursing monitoring action to prevent treatment-related complications during a therapy, which aligns with NCLEX Reduction of Risk Potential—Potential for Complications.

Question 28

A nurse is caring for a client who has pneumothorax and a chest tube with closed water seal drainage system. Which of the following actions should the nurse take?

Accepted Answer

Answer reason: Maintaining the prescribed water level in the water-seal chamber is essential to preserve the one-way valve effect that prevents air from flowing back into the pleural space. Evaporation or accidental loss of water can break the seal and increase the risk of recurrent pneumothorax. Routine stripping/milking can create excessive negative pressure and may damage tissue, so it is not performed as a standard scheduled action. The system is typically kept closed and below chest level; routine “emptying” is not done on a fixed schedule unless ordered/needed, and dressing changes follow facility policy and clinical indication.
Category reason: This question tests nursing management of a chest tube drainage system to prevent complications (loss of water seal, re-accumulation of air), which aligns with monitoring and preventing treatment-related complications.

Question 29

A nurse is assessing a client who is 12hr postoperative following a colon resection. Which of the following findings should the nurse report to the surgeon?

Accepted Answer

Answer reason: At 12 hours post–colon resection, a hemoglobin this low is abnormal and raises concern for acute blood loss or postoperative hemorrhage. Early recognition and prompt provider notification are critical to prevent hemodynamic instability and shock. The other findings are either expected postoperatively (transient absent bowel sounds) or within normal/less urgent ranges in this context.
Category reason: This item tests nursing recognition of an abnormal postoperative laboratory finding and the need to escalate care for a potential complication, which aligns with monitoring for complications under Reduction of Risk Potential.

Question 30

A nurse is caring for a client who has impaired renal function. For which of the following findings should the nurse notify the provider?

Accepted Answer

Answer reason: A. Urine output of 175 mL in the past 8 hr This reflects oliguria (about 22 mL/hr), which is below the expected minimum urine output (~30 mL/hr) and can indicate worsening renal perfusion or acute kidney injury. In a client with impaired renal function, a decreasing urine output is a high-risk change that can rapidly lead to fluid overload, electrolyte/acid–base disturbances, and uremic complications. The provider should be notified promptly for evaluation and potential interventions (e.g., labs, fluid management, medication review).
Category reason: The question tests nursing recognition of a clinically significant assessment finding and the need to escalate care to prevent deterioration, which aligns with monitoring for complications under Reduction of Risk Potential.

Question 31

A nurse is assessing an adolescent who has type 1 diabetes mellitus. Which of the following findings is the nurse's priority?

Accepted Answer

Answer reason: This indicates chronically poor glycemic control over the prior ~2–3 months, placing the adolescent at high risk for both acute complications (e.g., DKA from inadequate insulin) and accelerated development of long-term microvascular complications. Compared with the other findings, it reflects sustained hyperglycemia requiring prompt evaluation of the insulin regimen, adherence, and education, rather than an isolated or expected/less urgent value. The listed preprandial glucose is near goal, and mild glycosuria can occur with transient elevations, while the cholesterol value is not an immediate safety threat.
Category reason: This is a patient-care prioritization question about which assessment finding requires the most urgent nursing attention to prevent diabetes-related complications, fitting NCLEX Reduction of Risk Potential (Potential for Complications).

Question 32

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

Accepted Answer

Answer reason: A. Nasal congestion After transsphenoidal pituitary surgery, airway and nasal passages can be affected by edema and retained secretions, and the presence of nasal packing can obstruct breathing. Nasal stuffiness can also tempt the client to blow the nose, which increases intracranial pressure and can precipitate bleeding or disrupt the surgical site. Early recognition supports prompt airway support and reinforcement of postoperative precautions (avoid coughing/straining and nose blowing). The other options are not typical priority complications specific to the transsphenoidal nasal route.
Category reason: This item tests postoperative nursing surveillance for procedure-specific complications after transsphenoidal surgery, which aligns with monitoring for potential complications in Reduction of Risk Potential.

Question 33

A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances?

Accepted Answer

Answer reason: Removing CSF when intracranial pressure is elevated can create a pressure gradient that precipitates brain herniation, a life-threatening complication. Clients with suspected increased ICP (e.g., signs such as projectile vomiting, severe headache, altered level of consciousness, papilledema) should not undergo LP until elevated pressure is excluded, typically with neuroimaging. In subarachnoid hemorrhage, LP may reveal blood/xanthochromia, but anticipated blood is not a contraindication; the primary safety issue is preventing herniation.
Category reason: This question tests nursing recognition of a serious procedure-related complication and when to withhold/avoid an LP for safety, which aligns with monitoring for and preventing complications under Reduction of Risk Potential.

Question 34

A nurse is reinforcing teaching with a client who has HIV and is being discharged to home. Which of the following instructions should the nurse include in the teaching?

Accepted Answer

Answer reason: Monitoring daily temperature helps detect early signs of infection, which is a major complication risk for clients with HIV due to immune suppression. Prompt recognition of fever supports earlier contact with the provider and timely evaluation/treatment. The other options are either routine hygiene without specific complication surveillance benefit or include potentially unsafe exposure (e.g., cat feces can transmit toxoplasmosis), so they are not the best instruction to emphasize.
Category reason: This question tests discharge teaching aimed at preventing and detecting complications (infection) in an immunocompromised client, which aligns with monitoring for potential complications.

Question 35

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

Accepted Answer

Answer reason: This suggests active bleeding and possible clot formation after TURP, which can obstruct the urinary catheter and lead to acute urinary retention and bladder distention. Early identification is critical because worsening hemorrhage can progress to hemodynamic instability and requires prompt provider intervention (e.g., adjusting continuous bladder irrigation, evaluating for clot retention). The other findings are common postoperative issues that are typically less urgent and can often be managed with routine nursing measures and monitoring.
Category reason: This question focuses on recognizing and reporting a high-risk postoperative complication after TURP, aligning with monitoring for and preventing complications under Reduction of Risk Potential.

Question 36

To induce labor in a client, artificial rupture of the membranes is done. What is the immediate nursing action following this procedure?

Accepted Answer

Answer reason: Artificial rupture of membranes can precipitate acute fetal compromise, most importantly from umbilical cord prolapse or compression after the sudden loss of cushioning fluid. The priority immediate action is to assess fetal status by checking FHR right away and continuing close monitoring for several minutes. Early detection of bradycardia or variable decelerations allows rapid interventions (e.g., maternal repositioning, notifying the provider, preparing for emergent delivery) to prevent fetal hypoxia. Comfort measures, hygiene, and reassurance are appropriate but should follow the urgent fetal assessment.
Category reason: This is a nursing priority question focused on the immediate post-procedure assessment to detect and respond to potential maternal-fetal complications, which aligns with Reduction of Risk Potential—Potential for Complications.

Question 37

A patient is on an oral contraceptive. Which of the following is MOST important to be reported immediately?

Accepted Answer

Answer reason: This can indicate deep vein thrombosis, a serious adverse effect associated with estrogen-containing contraceptives that can progress to pulmonary embolism. New unilateral calf/thigh pain (often with swelling, warmth, or redness) requires urgent evaluation and stopping the medication until assessed. Nausea, mild abdominal bloating, and libido changes are common non-urgent side effects that are typically monitored rather than treated as emergencies.
Category reason: This item tests nursing judgment about recognizing a high-risk medication complication and taking prompt action to prevent deterioration, which aligns with monitoring for potential complications.

Question 38

While waiting for the obstetrician, an antepartum client at 32 weeks’ gestation positioned herself supine on the examination table. As the nurse enters the examination room, the client says, “I’m feeling a little lightheaded and sick to my stomach”. The nurse noted that the client may be experiencing vena cava syndrome (hypotensive syndrome) and should take which immediate action?

Accepted Answer

Answer reason: In late pregnancy, lying supine can compress the inferior vena cava and reduce venous return, leading to decreased cardiac output with hypotension, nausea, and lightheadedness. Immediate management is left uterine displacement by elevating the right hip or turning the client to the left side to relieve the compression and restore perfusion. Comfort measures (cool cloth, emesis basin) do not correct the hemodynamic cause, and calling the provider delays the urgent corrective positioning intervention.
Category reason: This item tests an immediate nursing intervention to prevent/worsen a physiologic complication (supine hypotensive syndrome) during pregnancy, aligning with managing potential complications in a clinical scenario.

Question 39

A female patient has a laparoscopic cholecystectomy this morning. She is now complaining of right shoulder pain. The nurse would explain to the patient this symptoms is?

Accepted Answer

Answer reason: Referred shoulder pain after laparoscopic procedures is typically caused by residual insufflation gas irritating the diaphragm and phrenic nerve. This is a frequent, expected postoperative finding and is usually self-limited, managed with ambulation, positioning, and analgesics as prescribed. It is not a hallmark effect of general anesthesia itself, and it does not specifically indicate pulmonary complications requiring incentive spirometry. Reporting is warranted if pain is severe, progressive, or accompanied by concerning signs (e.g., dyspnea, fever, hypotension), but isolated shoulder pain is commonly benign post-laparoscopy.
Category reason: This item tests nursing recognition of an expected postoperative symptom and monitoring for complications after a surgical procedure, aligning with reduction of risk potential and potential postoperative complications.

Question 40

A patient receiving packed RBCs develops chills, fever (101.5°F), and low back pain 15 minutes into transfusion. What should the nurse do first?

Accepted Answer

Answer reason: These findings shortly after starting packed RBCs are concerning for an acute hemolytic transfusion reaction, where continued infusion can rapidly worsen hemolysis, shock, and acute kidney injury. The priority nursing action is to stop the blood product to prevent further antigen exposure and progression of the reaction. After stopping, the nurse should maintain IV access with normal saline using new tubing, assess vital signs, and then notify the provider and blood bank per protocol.
Category reason: This item tests immediate nursing action to prevent harm from a transfusion reaction, which is managing a high-risk complication during therapy.

Question 41

A patient reports a severe headache after a lumbar puncture. What’s the most appropriate nursing action?

Accepted Answer

Answer reason: This presentation is most consistent with a post–dural puncture (low CSF pressure) headache, a common complication after lumbar puncture. Increasing oral fluids (often along with caffeine and supine positioning) supports hydration and may help reduce symptoms while monitoring for worsening. High Fowler’s can exacerbate the headache by further lowering intracranial CSF pressure when upright. Heat to the site and antihypertensives do not address the underlying CSF leak-related mechanism.
Category reason: This question tests the nurse’s appropriate intervention for a post-procedure complication (post–lumbar puncture headache), which aligns with monitoring and managing potential complications.

Question 42

A post-op patient has 200 mL of drainage from a surgical drain in 1 hour. What should the nurse do first?

Accepted Answer

Answer reason: C. Check the patient’s vital signs This amount of drainage in a short time can indicate hemorrhage or evolving shock, so the priority is rapid assessment for hemodynamic instability (BP, HR, RR, O2 sat) before other actions. Vital signs help determine urgency and guide immediate interventions (e.g., oxygen, IV access/fluids per protocol) and escalation. After assessment, the nurse should promptly notify the provider with objective findings and continue close monitoring of output and the surgical site.
Category reason: This is a nursing priority question focused on recognizing and responding to a potential postoperative complication (excessive drainage/possible bleeding), which aligns with monitoring for complications under Reduction of Risk Potential.

Question 43

A client has sustained a closed fracture and has just had a cast applied to the affected arm. The client is complaining of intense pain. The nurse has elevated the limb, applied an ice bag, and administered an analgesic, which was ineffective in relieving the pain. The nurse interprets that this pain may be caused by which condition?

Accepted Answer

Answer reason: Severe pain that is not relieved by elevation, ice, and prescribed analgesics after cast application is a warning sign of neurovascular compromise/compartment syndrome. Increasing tissue pressure reduces capillary blood flow, producing ischemia and escalating pain that is often disproportionate to the injury. This situation requires urgent neurovascular assessment (e.g., pulses, cap refill, sensation, movement) and immediate provider notification for possible cast loosening/bivalving to prevent permanent damage.
Category reason: This item tests recognition of a serious post-cast complication and the nurse’s interpretation of symptoms indicating compromised circulation, aligning with monitoring for and responding to potential complications.

Question 44

A nurse is assessing a patient who is present with suspected appendicitis. Which of the following findings would be most concerning and indicate a possible complication?

Accepted Answer

Answer reason: B. Sudden relief of pain followed by worsening symptoms This pattern is concerning for appendiceal rupture, where initial decompression can briefly lessen pain, followed by peritoneal irritation and systemic deterioration. Perforation increases the risk of peritonitis and sepsis, making it a complication that requires urgent escalation of care. The other findings are more consistent with uncomplicated appendicitis and are not as specific for a dangerous change in condition.
Category reason: This question tests recognition of a dangerous clinical change suggesting appendiceal perforation and the need to identify a complication during patient assessment, which aligns with monitoring for and identifying potential complications.

Question 45

A post-op patient who had an abdominal surgery 4 hours ago reports new onset of restlessness, tachycardia, and cool, pale skin. What is the priority nursing intervention?

Accepted Answer

Answer reason: C) Assess the surgical site & check for bleeding These findings shortly after surgery are classic for possible hypovolemia/hemorrhage (early shock), which is immediately life-threatening. The nurse’s priority is rapid assessment for a reversible cause, including inspecting the incision and dressings, checking drains, and correlating with vital signs to identify active bleeding. Treating pain or repositioning does not address the suspected complication and could delay recognition of deterioration. After confirming/strongly suspecting hemorrhage, the nurse would escalate care and initiate appropriate supportive measures per protocol.
Category reason: This question tests priority nursing action in response to early postoperative signs of a potential complication (hemorrhage/shock), aligning with monitoring for and responding to complications.

Question 46

A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications?

Accepted Answer

Answer reason: Amniocentesis in the third trimester can irritate the uterus and trigger preterm labor. Post-procedure monitoring focuses on early signs of labor such as uterine tightening, cramping, or increasing uterine activity, along with vaginal bleeding or fluid leakage. Detecting uterine activity promptly helps prevent or manage preterm birth complications. The other options are not the most direct expected complication specific to amniocentesis at this gestational age.
Category reason: This item tests post-procedure nursing monitoring to detect a complication (preterm labor) after an invasive prenatal diagnostic procedure, which fits monitoring for potential complications in Reduction of Risk Potential.

Question 47

The nurse is providing care for a pregnant 16-year-old client. The client says that she's When caring for a client who has had a cesarean birth, which action is inappropriate?

Accepted Answer

Answer reason: Initial postoperative cesarean dressings are typically left in place for the ordered timeframe to protect the incision and reduce infection risk; removing it without a provider order can disrupt the wound barrier and increase contamination. Incision assessment should be performed by observing for drainage on the dressing and monitoring systemic/local signs of infection, then changing/removing the dressing per protocol. Pain assessment and relief are appropriate postoperative priorities. Addressing psychosocial needs such as self-esteem is also appropriate, especially for an adolescent postpartum client.
Category reason: This item tests nursing care and prevention of postoperative complications after a cesarean birth (wound protection, infection risk, appropriate assessment actions), which aligns with NCLEX-style clinical judgment under reduction of risk/potential complications.

Question 48

The nurse is caring for a pre-adolescent client in skeletal Dunlop traction. Which nursing intervention is appropriate for this client?

Accepted Answer

Answer reason: A) Make certain the child's maintained in correct body alignment. Maintaining proper alignment keeps the traction force directed correctly, promoting fracture reduction and preventing neurovascular compromise, skin breakdown, and contractures. In skeletal traction, weights must hang freely and should not rest on the bed, so the alternative suggesting contact is unsafe. Bed adjustments can alter the line of pull and traction effectiveness unless specifically prescribed, and traction should not be released intermittently without a provider order because it can disrupt alignment and healing.
Category reason: This item tests nursing management of a client in skeletal traction, focusing on preventing complications and ensuring safe, effective therapeutic positioning—an NCLEX-style patient care intervention.

Question 49

A nurse is caring for a client who is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration?

Accepted Answer

Answer reason: GERD increases the likelihood of regurgitation of gastric contents into the esophagus and pharynx, especially with enteral feeding and when gastric volume is increased. Regurgitated material can be aspirated into the airway, raising the risk for aspiration pneumonia. In contrast, high-Fowler’s positioning reduces aspiration risk, and a residual of 65 mL is not typically considered a high residual that would strongly predict aspiration in most adult protocols. High-osmolarity formulas are more associated with GI intolerance (e.g., diarrhea) than aspiration risk.
Category reason: This question tests nursing risk assessment and complication prevention during enteral tube feeding, which aligns with monitoring for and preventing aspiration as a potential complication.

Question 50

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

Accepted Answer

Answer reason: This surgery passes through the nasal cavity and sphenoid sinus, so postoperative airway patency and nasal/sinus complications are key concerns. Edema, blood clots, and secretions can obstruct the nasal passages, and monitoring helps identify early respiratory compromise and local complications. The nurse should also be vigilant for CSF leak and meningitis risk after this approach, which commonly present with nasal drainage and related symptoms, making close nasal assessment particularly important.
Category reason: This question focuses on nursing surveillance for postoperative complications specific to a transsphenoidal pituitary procedure, which is an NCLEX-style patient safety/risk monitoring task.

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

Potential for Complications NCLEX Practice Test

Continue Learning