Question 1

What instruction should the nurse include in the discharge teaching plan of a client who had a cataract extraction today?

Accepted Answer

Answer reason: b. Light housekeeping is permitted but avoid heavy lifting After cataract extraction, patients should avoid activities that increase intraocular pressure such as bending, straining, and lifting heavy objects to reduce risk of hemorrhage or wound dehiscence. Light activity is typically acceptable as tolerated, but exertion restrictions are emphasized in early recovery. Wearing a protective shield is generally recommended during sleep rather than during the day, and medication sequencing usually places drops before ointment because ointment can block absorption.
Category reason: This is a post-operative discharge teaching question focused on preventing complications after an eye procedure, which fits Potential for Complications under Reduction of Risk Potential.

Question 2

Goals for safe patient discharge after varicose vein surgery include educating the patient

Accepted Answer

Answer reason: A. about potential complications that require physician contact. Postoperative discharge teaching must emphasize recognition of warning signs (e.g., bleeding, infection, worsening pain, signs of DVT/PE) and when to seek urgent care to prevent serious complications. This is a core safety goal and reduces risk by ensuring timely escalation if complications develop at home. The other options are unsafe or incorrect: activity is typically encouraged (not minimized), compression garment duration is individualized rather than a blanket 24-hour rule, and instructions should be in plain language rather than medical jargon.
Category reason: This item tests discharge education focused on preventing and responding to postoperative complications, which aligns with monitoring for and teaching about potential complications under Reduction of Risk Potential.

Question 3

A nurse is assisting with the care of a client who has a femur fracture and is in skeletal traction. Which of the following actions should the nurse take?

Accepted Answer

Answer reason: For skeletal traction to be effective, the traction force must be continuous and unobstructed; weights resting on the floor or bed reduce the pulling force and can worsen alignment and pain. Keeping the weights freely hanging maintains proper bone alignment and decreases the risk of neurovascular compromise and delayed healing. Knots should not be loosened by the nurse because that alters the prescribed traction. Skin and pin-site care are important, but maintaining correct traction mechanics is the key immediate action to prevent complications.
Category reason: This question tests nursing management of a client in skeletal traction and preventing complications by ensuring the traction system functions correctly, which is a patient-care safety intervention.

Question 4

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: A low gastric pH indicates highly acidic gastric contents and, in a postoperative client with gastric decompression/NG suction or stress-related mucosal disease risk, can suggest inadequate acid suppression and increased risk for mucosal injury and upper GI bleeding. Postoperative tachycardia would be more concerning if present, but a heart rate of 90/min is within expected range for many adults. Absent bowel sounds are expected early after bowel surgery due to postoperative ileus, and a WBC of 9.2 is within typical reference range and not by itself suggestive of infection.
Category reason: This item asks what postoperative finding should be reported to the surgeon, requiring nursing judgment about potential complications after a colon resection, which aligns with monitoring for complications under Reduction of Risk Potential.

Question 5

A client with a tracheostomy cough up thick secretion. What is the nurse's best action?

Accepted Answer

Answer reason: Thick tracheostomy secretions can obstruct the airway and impair ventilation, making airway clearance the immediate priority. Tracheal suctioning directly removes secretions and helps restore airway patency and effective gas exchange. Increasing fluids or giving an expectorant may help prevent future thickening but does not address acute obstruction risk. Reassurance alone is inappropriate when a potential airway complication is present.
Category reason: This is a nursing action question focused on preventing airway obstruction and managing a tracheostomy-related complication, which requires clinical judgment and intervention (NCLEX).

Question 6

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

Accepted Answer

Answer reason: A. Nasal congestion This procedure is performed through the nasal/sphenoid sinus route, so preoperative nasal obstruction can interfere with surgical access and increase the risk of mucosal trauma and bleeding. Identifying and reporting congestion or upper respiratory infection symptoms helps prevent perioperative complications and may lead to delaying surgery until inflammation resolves. The other options are not specific preoperative concerns for a transsphenoidal approach and are less likely to impact surgical feasibility and immediate safety.
Category reason: This item tests nursing surveillance for procedure-specific risks and preoperative complication prevention in a client undergoing transsphenoidal pituitary surgery, which fits Potential for Complications.

Question 7

An adolescent male receives a prescription for an antidepressant drug because he is exhibiting a depressed affect. While the client is taking the antidepressant, which comparison of the client's behavior before and after taking the drug is most important for the nurse to obtain?

Accepted Answer

Answer reason: Antidepressants can improve energy and psychomotor activity before mood and hopelessness fully lift. This creates a higher short-term risk that a depressed adolescent may act on suicidal thoughts because they now have more drive to carry out a plan. Monitoring changes in activity level helps detect this early and prompts immediate safety interventions. Appetite and social interaction are relevant, but they are less directly tied to imminent self-harm risk during early treatment.
Category reason: This question centers on nursing monitoring for a critical safety complication (increased suicide risk) after initiating antidepressant therapy, which fits Potential for Complications within Reduction of Risk Potential.

Question 8

A client post-cholecystectomy develops jaundice. What should the nurse do first?

Accepted Answer

Answer reason: Jaundice after cholecystectomy can indicate impaired bile flow from a retained stone, edema, or iatrogenic injury causing obstruction. The priority is to assess for this postoperative complication by checking for worsening jaundice, dark urine, clay-colored stools, pruritus, RUQ pain, fever, and reviewing liver function tests if available. Pain medication and ambulation do not address the potentially serious cause of the new finding. After focused assessment, prompt escalation to the surgical team is indicated based on findings.
Category reason: This is a postoperative nursing priority question focused on recognizing and assessing a potential complication (jaundice suggesting biliary obstruction) to reduce risk and guide timely intervention.

Question 9

A nurse is assessing a client's risk for pressure injuries. Which client is at highest risk?

Accepted Answer

Answer reason: Immobility is the strongest risk factor for pressure injuries because sustained pressure over bony prominences decreases tissue perfusion, leading to ischemia and breakdown. Older age further increases risk due to thinner skin, reduced subcutaneous padding, and poorer microcirculation, and stroke may add impaired sensation and inability to reposition. The other clients are generally mobile or have conditions not inherently associated with prolonged pressure and reduced mobility.
Category reason: This question asks the nurse to identify which patient is most at risk for a complication (pressure injury) based on clinical risk factors, which is a patient-safety risk assessment and fits Reduction of Risk Potential.

Question 10

A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hour for 2 hours. The client received a single bolus of 500 mL of intravenous fluid. Urine output for the last 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticipate that the client is at risk for which problem?

Accepted Answer

Answer reason: The client has oliguria despite an IV fluid bolus, suggesting reduced renal perfusion or early postoperative renal dysfunction rather than simple dehydration. Elevated BUN and creatinine indicate decreased glomerular filtration and impaired clearance of nitrogenous wastes. After cardiac surgery, risks such as hypotension, low cardiac output, and nephrotoxic exposures can precipitate acute tubular injury leading to acute kidney injury, which requires prompt assessment and intervention to prevent progression.
Category reason: This is a postoperative patient-care scenario requiring nursing judgment about interpreting urine output trends and rising renal labs to anticipate complications.

Question 11

The nurse is caring for a client after a lumbar puncture (spinal tap). Which client assessment is MOST concerning and requires a nursing response?

Accepted Answer

Answer reason: This finding suggests possible cerebrospinal fluid leakage from the puncture site, which is an abnormal post-procedure complication requiring prompt nursing action. Ongoing leakage can increase the risk of infection (e.g., meningitis) and contribute to intracranial hypotension with worsening neurologic symptoms. The nurse should assess the site, reinforce the dressing as appropriate per protocol, keep the client supine as ordered, and notify the provider for further evaluation and management.
Category reason: This is a post-procedure nursing assessment question focused on recognizing and responding to a potential complication after a lumbar puncture, which fits Reduction of Risk Potential → Potential for Complications.

Question 12

The nurse is preparing a client for emergency surgery to repair a depressed skull fracture. Which of the following actions would be essential for the nurse to take?

Accepted Answer

Answer reason: In emergency surgery, assessing last oral intake is critical to reduce the risk of aspiration during anesthesia and to guide airway management and perioperative planning. NPO status affects anesthesia induction decisions and whether rapid-sequence intubation and additional aspiration precautions are needed. The other options are not essential immediate preoperative safety assessments for an emergent depressed skull fracture compared with aspiration-risk evaluation.
Category reason: This is a perioperative nursing safety/intervention question focused on preventing anesthesia-related complications (aspiration risk), which aligns with Reduction of Risk Potential.

Question 13

A client has been hospitalized after an automobile accident. A full leg cast was applied in the emergency room. The most important reason for the nurse to elevate the casted leg is to?

Accepted Answer

Answer reason: Elevation decreases hydrostatic pressure in the injured extremity, which limits capillary filtration and thereby reduces edema within and around the cast. Less swelling lowers the risk of neurovascular compromise (e.g., impaired circulation, increasing pain, paresthesia) and supports adequate perfusion of distal tissues. Improved venous return also helps prevent venous stasis and related complications, making it the priority rationale over comfort or cast-drying concerns.
Category reason: This question tests a nursing intervention (elevating a casted extremity) aimed at preventing complications such as swelling and neurovascular impairment, which aligns with monitoring and preventing physiologic complications.

Question 14

The nurse is assessing a client 24 hours following a cholecystectomy. The nurse notes that the T-tube has drained 750 mL of green-brown drainage since the surgery. Which nursing intervention is most appropriate?

Accepted Answer

Answer reason: A T-tube after biliary surgery typically drains bile, and an output around 500–1000 mL/day in the first 24 hours can be expected. Green-brown drainage is consistent with bile and does not by itself indicate obstruction or hemorrhage. Clamping or irrigating without a specific prescription can increase risk of bile backup, leakage, or infection. Because the finding is within expected limits for the immediate postoperative period, the appropriate action is to record and continue routine monitoring.
Category reason: This is a postoperative nursing assessment question requiring clinical judgment about whether an expected finding needs intervention or escalation, which fits NCLEX patient-care decision-making under monitoring for complications.

Question 15

The nurse is assessing a 36-year-old woman who has been admitted for knee surgery. Which information obtained during the preoperative assessment should be reported to the surgeon before surgery?

Accepted Answer

Answer reason: This finding raises concern for possible pregnancy, which can significantly change perioperative planning due to fetal risk from anesthesia, medications, radiation exposure, and physiologic changes of pregnancy. The surgeon/anesthesia team may need pregnancy testing and may postpone elective surgery or modify the anesthetic plan. The other items are important for teaching and discharge planning, but they do not typically require immediate surgeon notification before proceeding with surgery.
Category reason: This question tests a preoperative nursing judgment about what assessment data must be escalated to prevent perioperative complications, which fits Reduction of Risk Potential (Potential for Complications).

Question 16

The PNP is examining a neonate with a heart murmur. The S2 sound is loudest at the apex. The respiratory rate is 65 breaths per minute, and the heart rate is 180 beats per minute. Which of the following would be an appropriate action by the PNP?

Accepted Answer

Answer reason: Tachypnea and tachycardia in a neonate with a murmur raise concern for clinically significant congenital heart disease and possible early heart failure, requiring prompt specialist evaluation. Waiting 24 hours risks deterioration and delays definitive assessment (e.g., echocardiography) and management. Increasing oral feeds can worsen fatigue and respiratory distress in an infant with possible cardiac compromise. Cardiac catheterization is invasive and is not the first-line diagnostic step without cardiology evaluation and noninvasive workup.
Category reason: This is a patient-care decision about appropriate referral and timely escalation to prevent complications from a potentially serious neonatal cardiac condition, aligning with nursing/advanced practice management of risk and complications.

Question 17

The nurse on a postpartum unit is preparing 4 clients for discharge. It would be MOST important for the nurse to see first which of the following clients before the others?

Accepted Answer

Answer reason: D. A 22-year-old who delivered by cesarean section and is reporting burning on urination Dysuria in the immediate postpartum period—especially after cesarean delivery with likely recent urinary catheterization—raises concern for urinary tract infection, which can progress to pyelonephritis or sepsis if not promptly assessed and treated. This complaint is not an expected normal postpartum finding and warrants focused assessment (vitals, bladder distention/retention, urine characteristics) and potential urine culture/antibiotics. The other clients describe either routine postpartum status or common/expected uterine afterpains (cramping) without red-flag symptoms.
Category reason: This is a nursing prioritization question requiring identification of the postpartum client most at risk for a complication needing prompt assessment and intervention, which fits NCLEX Reduction of Risk Potential (Potential for Complications).

Question 18

A nurse is planning care for a preschool-age child with the acute phase of Kawasaki disease. Which of the following interventions should the nurse include in the plan of care?

Accepted Answer

Answer reason: Kawasaki disease causes a systemic vasculitis with a major risk of coronary artery aneurysms, myocarditis, dysrhythmias, and heart failure, especially in the acute phase. Ongoing cardiac monitoring helps detect complications early and guides escalation of care (e.g., worsening perfusion, arrhythmias, signs of heart failure). Antibiotics are not indicated because the condition is not primarily bacterial, and playroom socialization is inappropriate when the child is acutely ill and potentially contagious until infection is ruled out. Fever management alone does not address the condition’s most dangerous complications.
Category reason: This asks for a nursing intervention to prevent/identify serious complications (cardiac involvement) during acute illness, which fits Reduction of Risk Potential—Potential for Complications.

Question 19

Vagina examination is contraindication during pregnancy?

Accepted Answer

Answer reason: Digital vaginal examination can disrupt placental tissue that overlies or is near the cervical os, triggering sudden, severe painless bleeding. In suspected placenta previa, assessment should avoid vaginal exams until placental location is confirmed by ultrasound. The priority is preventing hemorrhage and maternal-fetal compromise by minimizing cervical manipulation. Other listed conditions may warrant precautions but do not make vaginal examination classically contraindicated in the same immediate way.
Category reason: This is a pregnancy safety question focused on preventing a high-risk obstetric hemorrhage complication through avoidance of an unsafe assessment, aligning with Potential for Complications.

Question 20

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

Accepted Answer

Answer reason: C. Offering a pacifier Sucking increases tension on the lip suture line and can disrupt the surgical repair, leading to bleeding, dehiscence, and impaired healing. After cleft lip repair, comfort measures should minimize pressure and movement at the incision, using alternatives like holding, gentle rocking, or distraction. Many postoperative protocols avoid pacifiers and other sucking behaviors (including straws) until the surgeon allows them.
Category reason: This is a postoperative nursing-care decision focused on preventing complications (protecting the surgical incision) and selecting safe comfort interventions, which aligns with Reduction of Risk Potential—Potential for Complications.

Question 21

A nurse is caring for a client with hyperparathyroidism. What is a priority teaching point?

Accepted Answer

Answer reason: Hyperparathyroidism increases parathyroid hormone, which raises serum calcium and promotes hypercalciuria, increasing the risk of nephrolithiasis. Adequate hydration helps dilute urine and reduce calcium stone formation while supporting renal clearance of calcium. Teaching to restrict fluids would worsen stone risk and dehydration. Routine vitamin D or calcium supplementation can further increase calcium levels and is not a priority without specific provider direction.
Category reason: This is a nursing teaching/intervention question focused on preventing a common complication (kidney stones) in a client with hyperparathyroidism, which fits NCLEX risk-reduction and complication prevention.

Question 22

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

Accepted Answer

Answer reason: Administering a laxative when the cause of abdominal pain is unclear can worsen or mask an acute abdomen (e.g., appendicitis, bowel obstruction, perforation) and delay diagnosis and treatment. Laxatives increase intestinal motility and/or fluid in the bowel, which can precipitate complications if obstruction or inflammation is present. The nurse should hold the medication and notify the provider for further assessment.
Category reason: This item tests nursing judgment about medication safety—identifying when a prescribed laxative should be withheld to prevent worsening an undiagnosed potentially serious condition—so it fits Potential for Complications.

Question 23

The client receiving preoperative medication tells the nurse that all of the following medications (drugs or herbs) were ingested yesterday. Which one should the nurse report to the surgical team?

Accepted Answer

Answer reason: C. Motherwort Herbal supplements can significantly affect perioperative safety because they may alter coagulation, blood pressure, heart rhythm, and anesthesia/sedation requirements. Motherwort has cardiovascular effects and has been associated with increased bleeding risk, creating potential intraoperative and postoperative complications. Preoperative evaluation typically requires notifying the surgical/anesthesia team about any herbal use so they can adjust the plan and monitor for adverse effects.
Category reason: This item tests a nursing safety action in the perioperative setting—identifying a medication/herb that could increase surgical/anesthesia complications and reporting it—so it fits Reduction of Risk Potential (Potential for Complications).

Question 24

Which of the following statement made by a patient diagnosed with aortic valve stenosis calls for further education?

Accepted Answer

Answer reason: A. I’ll not limit strenuous activity if symptoms occur With aortic stenosis, strenuous exertion can precipitate syncope, angina, or sudden cardiac events because the fixed outflow obstruction limits the ability to increase cardiac output. Symptoms during activity are a warning sign that the heart cannot meet metabolic demands safely. Teaching should emphasize stopping activity and seeking medical evaluation if exertional symptoms occur. The other statements reflect appropriate risk reduction and follow-up.
Category reason: This question tests patient teaching and risk reduction to prevent complications in a client with a cardiac condition, which aligns with monitoring and preventing potential complications.

Question 25

The nurse returns to the nurse's station after making client rounds and finds four phone messages. Which of the following message should the nurse return FIRST?

Accepted Answer

Answer reason: " New paresthesia in an extremity with a cast can indicate neurovascular compromise from swelling and increased pressure, raising concern for compartment syndrome. This is time-sensitive because prolonged ischemia can lead to permanent nerve and muscle damage, and requires immediate assessment of circulation, sensation, movement, and pain, with prompt provider notification and possible cast adjustment/bivalving. The other complaints (pruritus with hepatitis A, nausea affecting intake, and insomnia with arrhythmia) are important but are less likely to represent an immediate limb-threatening complication.
Category reason: This question prioritizes which client message requires the most urgent nursing response based on risk of acute complications, aligning with identifying and preventing potential complications.

Question 26

Scenario: A surgical patient ate a banana 4 hours before scheduled procedure. Q. What is the correct nursing action?

Accepted Answer

Answer reason: Eating solid food 4 hours pre-op may violate NPO guidelines and increases aspiration risk during anesthesia induction, making this a perioperative safety issue. The nurse should not independently cancel, delay, or proceed because the appropriate plan depends on the type of anesthesia, urgency of surgery, and institutional policy. Promptly notifying anesthesia and the surgeon allows them to assess aspiration risk and decide whether to delay, modify anesthesia technique, or reschedule. This action prioritizes patient safety and appropriate interprofessional decision-making.
Category reason: This tests the nurse’s perioperative safety judgment to reduce anesthesia-related complications (aspiration) by escalating to the anesthesia/surgical team, which fits Reduction of Risk Potential—Potential for Complications.

Question 27

Neonatal Hyperbilirubinemia Concern A 2-day-old newborn has bilirubin of 16 mg/dL. What is the priority intervention?

Accepted Answer

Answer reason: At 48 hours of age, a total bilirubin of 16 mg/dL is high enough to warrant treatment to reduce the risk of bilirubin neurotoxicity (acute bilirubin encephalopathy/kernicterus). Phototherapy converts bilirubin into water-soluble isomers that can be excreted without conjugation, producing a faster and more reliable reduction than feeding alone. An IV fluid bolus is not indicated unless there are signs of dehydration or shock, and simply rechecking later delays necessary therapy. Feeding should be supported, but the priority is to promptly initiate phototherapy at this level.
Category reason: This is a patient-care priority question about an urgent nursing intervention to prevent complications from neonatal jaundice, aligning with monitoring and preventing clinical deterioration.

Question 28

Best position for unconscious patient to prevent aspiration is?

Accepted Answer

Answer reason: This position promotes drainage of oral secretions and vomitus away from the airway by using gravity, reducing the risk of aspiration in a patient without protective gag and cough reflexes. It also helps maintain airway patency compared with supine positioning, which encourages posterior tongue obstruction and pooling of secretions. Prone is not routinely used due to monitoring/airway access issues, and Fowler’s may not adequately protect an unresponsive patient who cannot control secretions.
Category reason: This question tests a nursing intervention to prevent a complication (aspiration) in an unconscious patient, which aligns with preventing physiologic complications in patient care.

Question 29

What is the first nursing action?

Accepted Answer

Answer reason: In any situation where an error or unexpected exposure may have occurred, the priority is immediate client safety using ABCs and focused assessment for harm. Monitoring identifies early deterioration so timely interventions can be initiated (e.g., stopping an infusion, supportive care, emergency response). After stabilizing and assessing the client, the nurse can then notify the provider and follow facility policy for reporting and disclosure. Documentation such as an incident report and notifying leadership are important but occur after the patient is assessed and protected from complications.
Category reason: This asks for the nurse’s first action to prevent or detect harm in a patient-care situation, which is an NCLEX-style prioritization/safety question focused on monitoring for potential complications.

Question 30

Following a thoracotomy, what position should the patient be placed in to facilitate lung expansion?

Accepted Answer

Answer reason: B. On unaffected side with HOB 30–45° Positioning with the head of bed elevated promotes diaphragmatic excursion and maximizes ventilation, helping prevent postoperative atelectasis. Lying on the non-operative (unaffected) side supports better expansion of the dependent lung and improves overall ventilation/perfusion compared with placing the surgical side down. Prone or flat positioning can restrict chest expansion and increase the risk of hypoventilation, while placing the operative side down can worsen pain-related splinting and reduce effective lung expansion.
Category reason: This is a postoperative nursing care decision focused on positioning to reduce respiratory complications and promote physiologic stability, which fits NCLEX Reduction of Risk Potential (Potential for Complications).

Question 31

What is the safest position for a client after a tonsillectomy?

Accepted Answer

Answer reason: This position promotes drainage of blood and secretions and helps prevent aspiration if postoperative bleeding occurs. After tonsillectomy, airway protection and early recognition of hemorrhage are key priorities; allowing secretions to pool in the oropharynx increases aspiration risk. Supine or head-extended positions can allow blood to collect in the throat and be swallowed, delaying detection of bleeding and increasing nausea/vomiting. Trendelenburg is unnecessary and can worsen airway and respiratory mechanics.
Category reason: This question tests a postoperative nursing intervention aimed at preventing aspiration and detecting hemorrhage, which is best categorized under monitoring and preventing complications.

Question 32

What is the earliest sign of decreased cardiac output in a post-op patient?

Accepted Answer

Answer reason: B. Decreased urine output The kidneys are highly sensitive to reduced perfusion, so a falling urine output is often an early indicator of impaired tissue perfusion and declining effective circulating blood flow after surgery. Compensatory vasoconstriction can preserve blood pressure initially, delaying hypotension until later in shock progression. Cool, clammy skin reflects sympathetic vasoconstriction but is less specific and may appear with other causes (e.g., ambient temperature). Cyanosis is typically a late finding, occurring after significant hypoxemia or severe circulatory compromise.
Category reason: This asks for early clinical recognition of a postoperative complication (decreased perfusion/decreased cardiac output) and relies on nursing assessment findings to detect deterioration, which fits Potential for Complications.

Question 33

Scenario: A patient recovering from bowel surgery is scheduled for NG tube removal. Which assessment must the nurse perform before removing the NG tube?

Accepted Answer

Answer reason: Return of bowel function is the key indicator of resolving postoperative ileus and readiness to discontinue gastric decompression. Bowel sounds and passage of flatus suggest gastrointestinal motility is returning, lowering the risk of abdominal distention, vomiting, and aspiration after tube removal. Hunger and nausea are subjective and can occur even when ileus persists. Checking the gag reflex is not a standard prerequisite for NG tube removal in this context and does not assess GI recovery.
Category reason: This is a nursing judgment question about assessing postoperative gastrointestinal recovery to prevent complications when discontinuing an NG tube, which aligns with monitoring for potential complications.

Question 34

Scenario: A patient with low sodium (Na+ 124 mEq/L) becomes confused and irritable. What is the nurse's priority?

Accepted Answer

Answer reason: Severe hyponatremia with new neurologic changes indicates risk of cerebral edema and seizures, which can rapidly become life-threatening. The immediate nursing priority is preventing injury and ensuring rapid recognition/response to seizure activity (e.g., padding side rails, suction/oxygen available, close monitoring). Reorientation and family presence may help confusion but do not mitigate the acute neurologic complication risk. Dietary sodium changes are too slow and are not the urgent intervention for symptomatic hyponatremia.
Category reason: This is a patient-care prioritization question focused on preventing complications and ensuring safety in an acute electrolyte imbalance, which aligns with NCLEX nursing judgment rather than foundational science recall.

Question 35

Which symptom is a warning sign in the second trimester?

Accepted Answer

Answer reason: Blurred vision in the second trimester is a danger sign that can indicate hypertensive disorders of pregnancy such as preeclampsia, especially when associated with headache, epigastric pain, or edema. Visual disturbances reflect possible cerebral or retinal involvement and require prompt assessment (blood pressure, urine protein) and provider notification. In contrast, backache, leg cramps, and increased appetite are common discomforts of normal pregnancy and are typically managed with routine comfort measures and education.
Category reason: This item tests recognition of a pregnancy danger sign and the need to identify potential maternal complications requiring prompt evaluation, which aligns with monitoring for complications in patient care.

Question 36

A nurse is assessing a client after permanent pacemaker implantation. Which finding is unexpected?

Accepted Answer

Answer reason: B. Small hematoma at site A hematoma suggests bleeding at the pocket or insertion site and should prompt closer assessment for expanding swelling, ecchymosis, pain, and potential hemodynamic effects, especially if the client is anticoagulated. After pacemaker implantation, expected findings include a stable heart rate, some incisional/shoulder discomfort, and temporary limitation of ipsilateral arm movement to reduce lead displacement risk. Because bleeding-related complications can progress, this finding is treated as unexpected compared with routine post-procedure discomfort and precautions.
Category reason: This item tests recognition of a post–pacemaker implantation complication and the nurse’s surveillance for procedure-related risks, which fits Reduction of Risk Potential (Potential for Complications).

Question 37

For an unconscious client to maintain airway and drain secretions, place them in:

Accepted Answer

Answer reason: This position helps keep the tongue from occluding the airway and allows saliva or vomitus to drain by gravity, reducing aspiration risk. Supine positioning increases the likelihood of airway obstruction and pooling of secretions. High Fowler’s is not appropriate for an unconscious client who cannot protect the airway and may slump, compromising airway patency. Trendelenburg can worsen ventilation and aspiration risk and is not used for routine airway protection.
Category reason: This question tests a nursing intervention to prevent airway obstruction and aspiration in an unconscious patient, which is a patient-safety complication-prevention decision within NCLEX care.

Question 38

After cataract surgery, avoid which position?

Accepted Answer

Answer reason: This position can increase pressure on the affected eye and disrupt the surgical site, raising the risk of complications such as increased intraocular pressure, bleeding, or wound dehiscence. Postoperative positioning aims to protect the operative eye from direct pressure and reduce strain. Clients are typically positioned to avoid rubbing or compressing the operative eye and to minimize activities or positions that increase venous pressure in the head and neck.
Category reason: This item tests nursing postoperative positioning to prevent eye surgery complications, which is a patient-safety intervention consistent with monitoring and preventing complications.

Question 39

Ideal position to reduce intracranial pressure (ICP):

Accepted Answer

Answer reason: This positioning promotes venous drainage from the brain by avoiding neck flexion/rotation and using modest head elevation, which helps lower intracranial blood volume and thereby decreases ICP. Excessive elevation (e.g., high Fowler’s) can reduce cerebral perfusion pressure by lowering mean arterial pressure at the level of the brain. Trendelenburg and leg elevation increase venous return and central venous pressure, which can impede cerebral venous outflow and raise ICP.
Category reason: This item tests a nursing intervention (patient positioning) used to prevent worsening neurologic complications by reducing ICP, aligning with monitoring and preventing complications under Reduction of Risk Potential.

Question 40

After a total laryngectomy, the nurse should place the client in?

Accepted Answer

Answer reason: This position promotes optimal airway patency and ventilation while decreasing neck and incision edema after major neck surgery. Elevation also helps reduce venous congestion and supports drainage, lowering the risk of bleeding and swelling that could compromise the new airway. Flat supine, neck flexion, or Trendelenburg can increase aspiration risk, impair respiratory mechanics, and worsen swelling in the operative area.
Category reason: This item tests immediate postoperative nursing positioning to prevent respiratory and edema-related complications after airway surgery, which is a patient-care intervention under Potential for Complications.

Question 41

After a supratentorial (cerebral hemisphere) craniotomy, the nurse should position the patient.?

Accepted Answer

Answer reason: B. On non-operative side with HOB elevated Head-of-bed elevation promotes venous drainage and helps limit increases in intracranial pressure after a supratentorial craniotomy. Positioning on the non-operative side avoids placing direct pressure on the surgical site and can reduce dependent edema at the incision. Trendelenburg and head-down positions impede venous return from the brain and can worsen intracranial hypertension, while lying flat can also increase ICP risk in the early postoperative period.
Category reason: This is a postoperative nursing care question focused on safe positioning to prevent complications such as increased intracranial pressure after a craniotomy, aligning best with Potential for Complications.

Question 42

A client on lithium reports excessive thirst and frequent urination. What should the nurse do first?

Accepted Answer

Answer reason: Excessive thirst and frequent urination can indicate lithium-induced nephrogenic diabetes insipidus and may also signal rising lithium toxicity risk, especially if dehydration is present. The priority is to assess for a potentially dangerous complication by checking the serum level and correlating with renal function and hydration status. Giving fluids or notifying the provider may be necessary, but assessment data are needed first to guide safe, timely intervention. Teaching is appropriate after immediate safety concerns are evaluated.
Category reason: This is a nursing priority/intervention question focused on recognizing a medication-related complication and initiating the first nursing action to reduce risk, which aligns with Potential for Complications under Reduction of Risk Potential.

Question 43

Which finding is most important to monitor after a coronary artery bypass graft (CABG)?

Accepted Answer

Answer reason: Post-CABG clients are at risk for postoperative bleeding and cardiac tamponade, and chest tube output is an early, objective indicator of these life-threatening complications. Sudden increases in drainage, persistent high output, or abrupt cessation (suggesting clotting/occlusion) require rapid evaluation and intervention. While glucose monitoring is important for healing and infection prevention, it is typically less immediately life-threatening than uncontrolled mediastinal bleeding. Appetite and pupillary reaction are not priority indicators of acute post-cardiac surgery complications.
Category reason: This question tests priority postoperative monitoring to detect complications (e.g., hemorrhage/tamponade) after cardiac surgery, which is a nursing surveillance and risk-reduction decision under Potential for Complications.

Question 44

A client who underwent pacemaker insertion complains of twitching in the chest muscles and hiccups. What is the priority?

Accepted Answer

Answer reason: C. Notify the provider Twitching of chest muscles and hiccups after pacemaker insertion can indicate diaphragmatic/phrenic nerve stimulation or lead displacement/malposition, which is a potential complication requiring prompt evaluation. This may need device interrogation, imaging, and possible lead repositioning or setting adjustment to prevent ineffective pacing and further complications. Comfort measures or reassurance alone could delay necessary assessment and corrective treatment. Increasing fluids or warm compresses does not address the likely device-related cause.
Category reason: This is a post-procedure patient-care question focused on recognizing and responding to a potential complication of pacemaker therapy, which fits NCLEX nursing judgment under Potential for Complications.

Question 45

A nurse is caring for a laboring woman receiving epidural anesthesia. What is the best position post-insertion?

Accepted Answer

Answer reason: This positioning helps prevent aortocaval compression by the gravid uterus, reducing the risk of maternal hypotension after epidural placement. Maintaining uteroplacental perfusion supports fetal oxygenation and decreases the likelihood of fetal heart rate decelerations. Prone is not feasible or safe in labor, and supine positioning increases the risk of supine hypotensive syndrome; high Fowler’s can also reduce venous return and worsen hypotension in this context.
Category reason: This question tests a nursing intervention to prevent a known complication (maternal hypotension and reduced uteroplacental perfusion) after epidural anesthesia, which aligns with monitoring and preventing physiologic complications.

Question 46

The nurse is caring for a child post-cardiac catheterization. How should the child be positioned?

Accepted Answer

Answer reason: B. Supine with affected leg straight This positioning helps maintain hemostasis at the arterial puncture site (commonly femoral) by minimizing hip flexion and movement that could disrupt the clot. Keeping the child supine with the affected extremity straight reduces the risk of bleeding and hematoma formation. It also supports accurate assessment for complications such as hemorrhage, decreased distal perfusion, or swelling at the insertion site. Alternative positions increase flexion or pressure changes that can precipitate bleeding.
Category reason: This question focuses on a nursing intervention aimed at preventing post-procedure complications (bleeding/hematoma) after cardiac catheterization, which aligns with monitoring and preventing potential complications.

Question 47

The nurse assesses a post-op patient after hypophysectomy (pituitary removal). What is a priority concern?

Accepted Answer

Answer reason: This finding suggests cerebrospinal fluid leakage (rhinorrhea), a serious post-hypophysectomy complication that creates a direct pathway for meningitis and can indicate a breach in the dura. It requires rapid provider notification, avoidance of actions that increase intracranial pressure (e.g., coughing, nose blowing), and prompt collection/testing of drainage (e.g., glucose/beta-2 transferrin). Constipation and mild headache are common post-op issues but are not as immediately life-threatening. Thirst can occur with diabetes insipidus after pituitary surgery, but CSF leak with glucose-positive drainage is the more urgent complication.
Category reason: This is a postoperative nursing assessment question focused on recognizing and responding to a high-risk complication (CSF leak) after a surgical procedure, which best fits Reduction of Risk Potential—Potential for Complications.

Question 48

Scenario: A post-op patient is reluctant to use the incentive spirometer. What teaching will the nurse provide?

Accepted Answer

Answer reason: Incentive spirometry promotes deep breathing and alveolar expansion after surgery, helping prevent atelectasis. By improving lung inflation and mobilizing secretions, it reduces the risk of postoperative pulmonary complications, including pneumonia. It does not directly prevent DVTs, and while it may improve comfort indirectly by easing ventilation, pain control is not its primary purpose.
Category reason: This question tests nursing teaching to reduce postoperative complications through an intervention (incentive spirometry), which fits preventing complications within Physiological Integrity.

Question 49

Scenario: A patient with a closed-system trach is on a ventilator. The nurse prepares to suction. Which step is most important to prevent complications?

Accepted Answer

Answer reason: Suctioning can rapidly remove oxygen from the airway and trigger hypoxemia, especially in ventilated patients with limited reserve. Providing extra oxygen beforehand reduces the risk of desaturation, bradycardia, and dysrhythmias during the procedure. Increasing suction pressure increases mucosal trauma and atelectasis risk, and routine saline instillation is not recommended because it can worsen oxygenation and push secretions deeper. Oral care is important for VAP prevention but does not address the immediate physiologic complication risk of suctioning.
Category reason: This item tests a nursing intervention performed to reduce the risk of physiologic complications (hypoxemia/dysrhythmias) during an airway procedure, aligning with monitoring and preventing complications rather than foundational science knowledge.

Question 50

A postpartum client reports persistent foul-smelling vaginal discharge and fever 4 days after delivery. The nurse suspects:

Accepted Answer

Answer reason: Foul-smelling lochia with postpartum fever several days after delivery is classic for uterine infection. Endometritis typically presents with uterine tenderness, malodorous discharge, and systemic signs such as fever and chills, and it requires prompt evaluation and antibiotics to prevent progression to sepsis. Normal lochia should not be persistently malodorous or associated with fever, and uterine involution is a normal physiologic process. Retained placental fragments more commonly cause subinvolution and heavy/prolonged bleeding; while they can predispose to infection, the key hallmark here is postpartum fever with foul odor suggesting infection as the primary problem.
Category reason: This is a postpartum nursing assessment question focused on recognizing a likely complication (uterine infection) based on symptoms and determining the suspected condition, aligning with monitoring for and identifying 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