Question 1

A 9-year-old child is examined because his mother noticed lesions on his tongue. Painless, slightly depressed, red lesions bordered with white bands are seen on assessment. The mother reports that the patterns were different yesterday. Which condition would the nurse suspect?

Accepted Answer

Answer reason: Migratory, painless erythematous patches with shallow depapillation and a thin white border that change location and pattern day-to-day are classic for benign migratory glossitis. In contrast, Koplik’s spots are small bluish-white lesions on the buccal mucosa associated with measles and are not described as shifting tongue patterns. Stomatitis usually causes painful inflammation and ulcerations rather than painless, map-like lesions with changing borders. Scald burns would present with an acute injury history and painful mucosal damage rather than a waxing/waning patterned appearance.

Question 2

A 6-year-old child is diagnosed with herpes zoster of the left anterior chest. Which assessment finding should the nurse expect to find?

Accepted Answer

Answer reason: The hallmark symptom is neuropathic pain with localized tenderness that often precedes or accompanies clustered vesicles. A finding of linear burrows suggests scabies, not zoster. A diffuse distribution across multiple body areas is more consistent with varicella (chickenpox) rather than a localized dermatomal eruption.

Question 3

A 13-year-old girl is suspected of having structural scoliosis by her school nurse. What should the nurse ask the girl to do to help confirm her suspicion?

Accepted Answer

Answer reason: Structural scoliosis screening is best supported by a forward-bend assessment that accentuates rib or lumbar prominence due to vertebral rotation. The Adam’s forward bend maneuver allows the nurse to observe asymmetry of the thorax or paraspinal area from behind, which is a key physical finding suggesting structural curvature rather than postural variation. Viewing the child from the side primarily evaluates kyphosis or lordosis, not lateral curvature with rotation. Knee-chest or “arching the back” does not reliably elicit the rotational asymmetry used to screen for scoliosis in school-age children.

Question 4

The nurse is caring for the postsurgical client. Which outcome should indicate to the nurse that the client’s coughing and deep breathing (C&DB) are most effective?

Accepted Answer

Answer reason: Effective coughing and deep breathing should improve ventilation, mobilize secretions, and prevent atelectasis, which is best reflected by improved breath sounds on assessment. Clear, audible lung sounds across fields indicate air entry is adequate and there are no retained secretions or developing crackles/rhonchi from postoperative hypoventilation. A normal respiratory rate can be present even when atelectasis or secretion retention persists, so it is less specific. Productive coughing may occur but does not confirm that overall aeration is improved throughout the lungs.

Question 5

Prior to emergency surgery for an appendectomy, the client has an NG tube inserted for gastric decompression. Which assessment finding from the NG returns should the nurse evaluate as normal?

Accepted Answer

Answer reason: This color indicates expected digestive fluids rather than bleeding or tube malposition. Coffee-ground material suggests digested blood and would be abnormal and concerning for upper GI bleeding. Gastric aspirate is typically acidic rather than alkalotic, and the volume can vary widely with illness, intake, and suction settings, so a single low volume is not a reliable “normal” indicator.

Question 6

The rehabilitation nurse is caring for the client with a closed head injury. Which cognitive goal would be most appropriate for this client?

Accepted Answer

Answer reason: Cognitive rehabilitation after a closed head injury commonly targets attention, concentration, and executive functioning deficits with measurable, time-limited goals. Sustaining attention to a task for a specified duration is a direct, objective indicator of cognitive recovery and can be progressively increased as the client improves. Feeding independently is primarily a self-care/ADL (motor/functional) outcome rather than a cognitive one, and attending therapy for a set number of hours reflects participation/tolerance rather than cognition. Interacting appropriately is more aligned with psychosocial/behavioral goals and is less specific to core cognitive domains than sustained attention.

Question 7

The emergency department nurse is entering the room of a client who was at a baseball game and was hit in the head with a bat. Which intervention should the nurse implement first?

Accepted Answer

Answer reason: In suspected head injury, the first neurologic priority is a rapid assessment of level of consciousness using the least stimulation to identify immediate deterioration. Observing response to environmental stimuli (such as a door opening) provides an immediate, low-effort check of arousal and responsiveness before asking the patient to perform tasks. After this quick LOC check, the nurse can proceed with a focused neuro exam assessing orientation and motor strength. Motor commands like hand squeeze or leg movement can be delayed until after this initial LOC assessment because they require more patient cooperation and do not come before determining basic responsiveness.

Question 8

The 65-year-old client is diagnosed with macular degeneration. Which statement indicates the client understands the discharge teaching concerning this diagnosis?

Accepted Answer

Answer reason: ” Macular degeneration causes central vision distortion, and home monitoring aims to detect new metamorphopsia or scotomas early so treatment can be initiated promptly. Regular Amsler grid checks are a standard self-assessment to recognize subtle changes that may signal progression, especially conversion to wet AMD. Artificial tears address dry eye symptoms rather than retinal disease, so they don’t reflect understanding of macular degeneration care. Using low-watt bulbs can worsen function because patients typically benefit from increased, glare-controlled lighting; sunglasses may reduce glare but is not the key disease-monitoring teaching point.

Question 9

The nurse cares for a postoperative mastectomy client. A wound drain is attached to a Hemovac drainage system. Which action should the nurse take?

Accepted Answer

Answer reason: Postoperative closed-suction drains require routine monitoring to detect bleeding, blockage, or infection early and to trend output over time. Measuring and describing drainage amount and character provides objective data about wound healing and potential complications after mastectomy (e.g., hemorrhage or seroma formation). Clamping during emptying is not part of standard Hemovac management because it can disrupt the system’s function and increase risk of backflow or loss of suction integrity. Flushing or milking the tubing and manipulating the insertion site are generally avoided unless specifically prescribed, as they can introduce infection or damage tissue.

Question 10

A client comes to the clinic for a blood pressure checkup. The client takes antihypertensive medications at home. The nurse knows the medication is most likely not effective in controlling the client's blood pressure if the client complains of which common symptom of hypertension?

Accepted Answer

Answer reason: Poorly controlled hypertension can produce symptoms related to acute elevations in arterial pressure and cerebral vascular distention. A persistent or worsening headache is a classic symptom nurses associate with elevated blood pressure and potential hypertensive urgency, suggesting current therapy may be insufficient or adherence is poor. By contrast, blurred vision can occur but is less consistently reported and often reflects longer-term retinal involvement rather than a simple indicator of day-to-day control. Decreased urine output and dependent edema are more suggestive of renal dysfunction or fluid overload/heart failure and are not the most common direct symptom used to flag uncontrolled essential hypertension in routine assessment.

Question 11

The nurse instructs a client diagnosed with chronic obstructive pulmonary disease (COPD) about positions to use during times of dyspnea. The nurse recognizes further teaching is necessary when the client states?

Accepted Answer

Answer reason: During dyspnea in COPD, positioning should maximize chest expansion and recruit accessory muscles while reducing the work of breathing. Lying flat promotes diaphragmatic elevation, decreases lung expansion, and can worsen ventilation-perfusion matching, making shortness of breath worse. Forward-leaning “tripod” positions (sitting with elbows on knees or leaning over a table) and upright support (leaning against a wall) help stabilize the shoulder girdle and improve breathing efficiency. Therefore, stating a plan to lie supine indicates misunderstanding and need for further teaching.

Question 12

The nurse cares for a client with a history of diabetes mellitus. The nurse notes that the client’s skin is cool and clammy and that the client is difficult to arouse. Which action should the nurse take first?

Accepted Answer

Answer reason: Cool, clammy skin and decreased level of consciousness in a client with diabetes strongly suggests acute hypoglycemia, which is an immediate threat to the brain and requires rapid recognition. The first nursing action is to validate the suspected cause with an immediate bedside glucose check so treatment can be targeted and monitored. Giving oral juice is unsafe if the client is difficult to arouse because of aspiration risk, and IV dextrose is typically reserved once hypoglycemia is confirmed or if testing is not immediately available with severe symptoms. Administering insulin would worsen hypoglycemia and is contraindicated in this presentation.

Question 13

A client has been diagnosed with active tuberculosis (TB). The nurse should assess the client for?

Accepted Answer

Answer reason: Active pulmonary TB classically presents with constitutional symptoms (fever, chills, night sweats) plus respiratory findings from lung involvement. Hemoptysis can occur due to cavitary disease and airway inflammation/erosion, making it a key symptom to assess when TB is active. The other options suggest alternative conditions (e.g., meningitis with headache/photophobia) or nonspecific findings not most characteristic of TB. Identifying this symptom cluster supports timely isolation precautions and monitoring for complications such as worsening respiratory status.

Question 14

The nurse is caring for a client with type 1 diabetes mellitus. At 3:00 a.m., the nurse finds the client manifesting mild confusion and diaphoresis and complaining of palpitations. Which of the following should the nurse do first?

Accepted Answer

Answer reason: Symptoms like diaphoresis, palpitations, and confusion strongly suggest hypoglycemia, but immediate assessment is needed to confirm and guide safe treatment. A bedside glucose check is rapid, noninvasive, and distinguishes hypoglycemia from other causes (e.g., anxiety, arrhythmia, or hyperglycemia) that would change management. If the value confirms low glucose and the client can swallow safely, oral carbohydrates would be appropriate next; if not able to take PO, glucagon would be indicated. Calling for additional insulin would be unsafe because insulin can worsen unrecognized hypoglycemia.

Question 15

The nurse is reviewing a client’s chart and notes a low serum calcium level. The nurse assesses the client and notes development of a carpopedal spasm when blood flow in the arm is occluded for a few minutes with a blood pressure cuff. The nurse interprets this as which sign?

Accepted Answer

Answer reason: Inflating a blood pressure cuff and occluding arterial flow can provoke carpopedal spasm, which is the classic elicited finding for this sign. This cuff-induced spasm specifically indicates tetany related to low calcium rather than a facial nerve irritability test. A common distractor is Chvostek’s sign, which is triggered by tapping the facial nerve and causes facial muscle twitching, not carpopedal spasm. Recognizing this distinction supports timely identification of hypocalcemia and risk for complications such as laryngospasm or seizures.

Question 16

A client has a history of chronic renal failure and receives hemodialysis treatments three times a week through an arteriovenous (AV) fistula in the left arm. What is the most important intervention for the nurse to provide?

Accepted Answer

Answer reason: AV fistula patency is critical because it is the client’s lifeline for hemodialysis, and loss of flow can rapidly lead to thrombosis and inability to dialyze. A palpable thrill and an audible bruit indicate adequate blood flow through the access; absence or change suggests occlusion or stenosis requiring prompt action. This assessment is prioritized over routine dressing practices because it directly evaluates function and early complications. Using the affected arm for blood pressure can impair flow and damage the access, making that choice unsafe.

Question 17

The nurse observes that the client, 3 days post MI, seems unusually fatigued. Upon assessment, the client is dyspneic with activity, has sinus tachycardia, and has generalized edema. Which action by the nurse is most appropriate?

Accepted Answer

Answer reason: The findings (dyspnea on exertion, sinus tachycardia, generalized edema) suggest worsening fluid retention and possible developing heart failure after an MI. Daily weight comparison is the most sensitive, objective bedside measure of fluid status and helps quantify the severity and trend of volume overload. This assessment data supports timely escalation of care (e.g., notifying the provider for diuretics, adjusting activity, evaluating for pulmonary congestion). High-flow oxygen is not indicated without evidence of hypoxemia and can be unnecessary or harmful, and simply resting or routine rhythm monitoring does not address the suspected volume overload driving the symptoms.

Question 18

The nurse is admitting the client with gastric cancer to an oncology unit for treatment. Which assessment finding should prompt the nurse to review the medical record to determine whether the cancer may have metastasized to the peritoneal cavity?

Accepted Answer

Answer reason: Peritoneal metastasis commonly leads to malignant ascites due to tumor seeding of the peritoneum, increased vascular permeability, and impaired lymphatic drainage. New or worsening abdominal fluid accumulation in a patient with gastric cancer is therefore a key assessment cue suggesting possible peritoneal involvement and warrants record review for staging, prior imaging, and cytology results. Nausea and rapid weight loss are nonspecific systemic effects of gastric cancer and treatment and do not localize spread to the peritoneal cavity. Grey Turner’s sign indicates retroperitoneal bleeding (classically severe pancreatitis or hemorrhage), not peritoneal metastasis.

Question 19

The client is at risk for septic emboli after being diagnosed with meningococcal meningitis. Which action by the nurse directly addresses this risk?

Accepted Answer

Answer reason: Regular extremity vascular checks (pulses, capillary refill, skin color/temperature, sensation, pain) directly assess for embolic complications and support urgent escalation if findings change. Hourly vital signs help detect sepsis progression but do not specifically evaluate embolic occlusion to tissues. Neurologic checks target intracranial complications, and vaccination is preventive for future exposure rather than management of the current embolic risk.

Question 20

The nurse is completing an admission assessment of the client with a possible obstructing struvite calculus of the right ureter. Which is the best question for the nurse to ask?

Accepted Answer

Answer reason:  Struvite stones are classically associated with recurrent infections by urease-producing organisms, which alkalinize urine and promote magnesium-ammonium-phosphate crystal formation. Asking about chronic or recurrent UTIs directly assesses the most important risk factor and supports the suspected stone type. Flank pain location may help laterality but does not clarify etiology, and left-sided pain would not best match a right ureter concern. The diet question targets uric acid stone risk, and juice preference is not the key discriminator for struvite calculi.

Question 21

The nurse is caring for the client diagnosed with obstructing left ureterolithiasis. The nurse evaluates that the client may have passed the calculi in the urine when which outcome has been achieved?

Accepted Answer

Answer reason: When the calculus passes into the bladder and the obstruction resolves, the characteristic colicky pain typically stops. Adequate urine output and clear urine can occur even with a partially obstructing stone and therefore are not reliable indicators of passage. The option mentioning hematemesis is not relevant to ureterolithiasis and does not assess resolution of the obstruction.

Question 22

A resident of a long-term care facility tells the nurse, “I’m having a hard time hearing people talk and can’t understand the voices on TV.” Which action is most appropriate?

Accepted Answer

Answer reason: New hearing difficulty should be approached with assessment first to identify reversible or urgent causes before initiating teaching or treatments. Otoscopic inspection can detect common, correctable problems in older adults such as cerumen impaction, foreign body, or otitis externa that can distort speech perception (e.g., TV voices). Proceeding directly to irrigation is unsafe without first visualizing the ear canal and tympanic membrane because irrigation is contraindicated with suspected perforation or infection and may worsen symptoms. Communication tips like reducing background noise or lip-reading can help, but they should follow an assessment that clarifies the underlying cause and appropriate referrals.

Question 23

The 60-year-old client notices a gradual decline in visual acuity and asks if it could be from a cataract. Which question will help determine whether a cataract is developing?

Accepted Answer

Answer reason:  Cataracts cause progressive lens opacification, leading to gradual blurred vision and reduced color discrimination (often colors look faded or yellowed). Asking about changes in color perception targets this common early symptom and helps differentiate cataracts from retinal conditions. Distorted or wavy vision suggests macular pathology (e.g., macular degeneration). A dark central field points toward central scotoma from macular disease, and random flashes of light are more consistent with retinal traction or detachment risk rather than cataract.

Question 24

The nurse is admitting the infant with a tentative diagnosis of intussusception. Which question to the mother would be most helpful in obtaining additional information to confirm intussusception?

Accepted Answer

Answer reason:  Intussusception classically causes intermittent, severe, crampy abdominal pain from telescoping bowel, so a key confirming history is episodic pain behaviors (sudden crying, drawing knees to chest, periods of lethargy between episodes). This question elicits the hallmark pattern and timing of pain, which is more specific than nonspecific symptoms like vomiting. Ribbonlike stools point more toward Hirschsprung disease or stenosis, not intussusception. Asking about a palpable mass is less reliable for a caregiver to detect and may miss the typical “sausage-shaped” finding that is usually identified on clinician exam.

Question 25

When the nurse is preparing to assess the infant, the infant’s mother tells the nurse that she herself has a history of eczema. Knowing this, it is most important for the nurse to assess the infant for which problems?

Accepted Answer

Answer reason: An infant with a family history is at higher risk for eczema and should be assessed for typical early-life inflammatory rashes and irritant/contact patterns that may coexist or be mistaken for it. Seborrheic dermatitis and diaper dermatitis are common in infancy and require differentiation because management and counseling differ (barrier protection/irritant avoidance vs emollients and anti-inflammatory therapy). In contrast, poison ivy/oak exposure and mite infestation/scabies are not specifically increased due to a parental eczema history and depend more on exposure history and contagious contacts.

Question 26

The nurse is closely monitoring the hospitalized infant who has an acute URI. The nurse’s close monitoring is based on knowing that the infant has an increased risk for severe consequences due to which factor?

Accepted Answer

Answer reason: Infants have small-diameter upper airways, so even mild mucosal edema and secretions from a URI markedly increase airway resistance and work of breathing (small radius changes greatly reduce airflow). This makes infants more prone to rapid respiratory compromise and obstruction compared with older children. The positive-airway-pressure statement is incorrect because infection tends to increase resistance rather than create beneficial pressure. The hypoxia response in infants can be blunted (they may fatigue and develop apnea), so relying on increased effort as protection is unsafe.

Question 27

While assessing a client with dilated cardiomyopathy, the nurse notices that the electrocardiogram (ECG) rhythm no longer has any P waves, only a fine wavy line. The ventricular rhythm is irregular with a QRS duration of 0.08 seconds. The heart rate is 110 beats/minute. The nurse interprets this rhythm as?

Accepted Answer

Answer reason: Absent distinct P waves with a fine, wavy baseline indicates chaotic atrial electrical activity rather than organized atrial depolarization. An irregularly irregular ventricular rhythm with a narrow QRS (0.08 sec) supports a supraventricular origin with variable AV nodal conduction, which is classic for this rhythm. Ventricular fibrillation would produce a disorganized waveform without identifiable QRS complexes and would not present as a stable narrow-complex rhythm. Atrial flutter typically shows sawtooth flutter waves and is often regular or regularly irregular, and sinus tachycardia would have normal P waves preceding each QRS.

Question 28

The nurse is performing a neurovascular assessment on a client who was admitted with a right fractured femur. The nurse noticed that the pulses are not palpable. What is the most important action of the nurse?

Accepted Answer

Answer reason: Absent distal pulses after a femur fracture can indicate acute neurovascular compromise, which requires immediate, accurate assessment of perfusion. If pulses are not palpable, using a Doppler is the fastest bedside method to confirm whether arterial flow is present and to establish an objective baseline for escalation. Waiting an hour risks progression to limb-threatening ischemia/compartment syndrome, and notifying others without confirming may delay targeted urgent management or result from a false-negative palpation finding (e.g., edema, obesity, weak pulses). Once Doppler confirms absent/markedly diminished flow, the provider should be notified urgently for definitive intervention.

Question 29

A 64-year-old client with complications related to metastatic cancer and complaints of back pain is admitted to the hospital. Which assessment finding should the nurse expect during the physical examination?

Accepted Answer

Answer reason: These fractures may produce an abrupt, sharp-angled kyphotic deformity (a focal prominence) on inspection and palpation rather than a smooth, gradual curve. This focal deformity is classically described as a gibbus/gibbous and fits the presentation of severe back pain with malignancy. A smooth rounded thoracic convexity is more typical of age-related osteoporosis or postural kyphosis, not a focal collapse from metastatic disease.

Question 30

A client has been treated with a 10-day course of antibiotic therapy for right lower lobe pneumonia and is scheduled to be discharged today. Select the assessment finding that indicates the client is ready to be discharged?

Accepted Answer

Answer reason: Vesicular breath sounds are expected normal breath sounds; hearing them at the previously affected base suggests the consolidation/inflammatory process has resolved or significantly improved. In contrast, continued dyspnea and tachypnea (RR 32) indicate ongoing increased work of breathing and inadequate respiratory recovery. A high fever signals persistent infection or complication and would warrant further evaluation rather than discharge.

Question 31

The nurse is caring for a 4-year-old client with a chest tube that has been placed on water seal. The nurse assesses the chest tube and determines that it is functioning correctly when which of the following occurs?

Accepted Answer

Answer reason: A functioning water-seal chamber should show tidaling with respiration because intrapleural pressure changes are transmitted through the chest tube to the water-seal column. In a spontaneously breathing child, inspiration creates more negative intrathoracic pressure, pulling the water level up; expiration allows it to fall. Continuous bubbling in the water-seal chamber suggests an air leak rather than normal function, whereas gentle bubbling in the suction chamber indicates suction is being applied (not specifically that the water seal is functioning). Clamping the tube to “obtain” a water seal is unsafe and can precipitate a tension pneumothorax; the device’s water-seal chamber provides the one-way valve effect without clamping.

Question 32

The client is admitted with a tentative diagnosis of hepatitis. The nurse determines that which client statement would be consistent with hepatitis?

Accepted Answer

Answer reason:  Hepatitis commonly causes anorexia, nausea, and aversions to foods/odors due to impaired hepatic function and systemic inflammation. A new intolerance to cigarettes (often described as a foul taste or aversion) is a classic early, nonspecific symptom seen with acute hepatitis. The other options point more toward GERD-related sleep disruption, lactose intolerance, or cardiopulmonary limitation rather than liver inflammation. Therefore, the statement reflecting a new aversion is most consistent with hepatitis.

Question 33

The client newly admitted to the PACU is showing signs of airway obstruction, and the nurse intervenes. Which assessment finding should initially indicate to the nurse that insertion of an oral airway has been effective?

Accepted Answer

Answer reason: An oral airway is effective when it relieves soft-tissue obstruction, allowing unobstructed airflow to the lower airways, which is reflected by clearer breath sounds on auscultation. Pulse oximetry may lag behind real-time airway improvement and can remain low from residual anesthetic effects, atelectasis, or hypoventilation. Blood pressure does not specifically reflect airway patency, and an abdominal breathing pattern can be a sign of increased work of breathing rather than effective airway maintenance.

Question 34

To ensure the accuracy of hemodynamic pressure readings, two baseline measurements are necessary. The first pressure reading is used to calibrate the system to atmospheric pressure, also known as “zeroing” the transducer. Which axis is the second pressure reading used to determine?

Accepted Answer

Answer reason: Accurate invasive hemodynamic monitoring requires both transducer zeroing and proper leveling to a consistent anatomical reference point to eliminate hydrostatic pressure error. The second baseline step determines the reference level at the right atrium (external landmark: 4th intercostal space at the mid-axillary line) so measured pressures reflect true intravascular pressure rather than patient position. If the transducer is positioned too high or too low relative to this reference, readings will be falsely low or falsely high, respectively. This concept is specific to arterial lines and central venous/PA catheter monitoring where leveling errors can lead to inappropriate clinical decisions.

Question 35

A nurse is caring for a client with a central line catheter that is attached to a monitor to observe central venous pressure (CVP). The client’s wife asks what the CVP measures. The nurse states?

Accepted Answer

Answer reason: CVP reflects right atrial pressure and is used clinically as an estimate of venous return and intravascular volume trends (preload), especially when interpreted with the overall clinical picture. A higher or lower CVP can suggest fluid overload or hypovolemia, respectively, though it is not a direct measure of total body fluid. It does not measure lung pressure (that would relate more to pulmonary artery pressures) and it does not directly measure cardiac output (how much blood the heart pumps). Heart rate is obtained from ECG/monitoring and is not what a CVP transducer measures.

Question 36

The nurse is assessing a 30-year-old primigravida in her second trimester who has a history of rheumatic fever. The client tells the nurse that her fingers feel tight and sometimes she feels as though her heart skips a beat. The nurse is most concerned when the client has which assessment finding?

Accepted Answer

Answer reason: Runs of atrial tachycardia indicate an episodic supraventricular arrhythmia that can reduce ventricular filling time and compromise maternal cardiac output and uteroplacental perfusion. The client’s report of “skipped beats” aligns with intermittent tachyarrhythmias rather than normal pregnancy changes alone. Sinus tachycardia and mild exertional dyspnea can be expected in pregnancy, but documented paroxysmal atrial tachycardia warrants prompt evaluation and management.

Question 37

A client is admitted to the emergency department with severe epistaxis. The physician inserts posterior packing. Later, the client is anxious and says he doesn’t feel he’s breathing right. Which nursing action is appropriate?

Accepted Answer

Answer reason: Posterior nasal packing can obstruct the airway if it dislodges or migrates, and it can also lead to pooled blood/secretions that threaten patency. A complaint of not breathing right after posterior packing requires an immediate focused airway assessment to identify obstruction or posterior bleeding into the oropharynx. Direct visualization of the posterior oral cavity helps detect a displaced pack, active bleeding, or a clot burden that would prompt urgent provider/ENT notification and airway support. Reassurance without assessment is unsafe, and removing the packing independently can precipitate uncontrolled hemorrhage; asking for clarification delays evaluating a potential airway problem.

Question 38

A client complains of chronic lower back pain and fatigue and has seen multiple care providers without relief of symptoms. The client insists that something is “terribly wrong.” Which action should the nurse take first?

Accepted Answer

Answer reason: The priority nursing principle is to first assess and rule out physiologic causes before attributing symptoms to psychological factors. Chronic pain and fatigue can reflect musculoskeletal disease, neurologic disorders, endocrine problems, anemia, infection, or medication/substance effects, and missing these creates significant risk. A comprehensive history and focused physical exam with appropriate screening directs safe next steps and prevents premature psychiatric labeling. Referrals to psychiatry, group therapy, or physical therapy may be appropriate later, but they are interventions that should follow an adequate assessment and identification of likely etiology.

Question 39

A mother was diagnosed with polyhydramnios during her pregnancy and just delivered a preterm male neonate. In which manner should the nurse assess a neonate for tracheoesophageal atresia?

Accepted Answer

Answer reason: The most direct bedside assessment is inability to pass an orogastric/nasogastric catheter into the stomach, which supports esophageal atresia and prompts confirmatory imaging and urgent management. Observation during feeding can provoke aspiration and is unsafe as a primary “test,” while cyanosis at birth is nonspecific and may not be present until feeding/secretions accumulate. Lung sounds for pneumonia may identify a complication (aspiration) but does not assess for the congenital defect itself.

Question 40

The nurse is assessing the client diagnosed with subacute bacterial endocarditis. Which question should the nurse ask the client during the admission interview to support this diagnosis?

Accepted Answer

Answer reason:  Subacute bacterial endocarditis often follows transient bacteremia from infections of the oropharynx or dental sources that seed abnormal or previously damaged valves. A recent sore throat can suggest a recent upper-respiratory infection that could have contributed to bacteremia preceding valve infection and helps correlate the timeline with a subacute presentation. Asking about remote, recurrent strep infections is more supportive of a history of rheumatic fever/valvular damage rather than establishing a recent precipitating event for the current diagnosis. Family history and current prescriptions are important admission questions but are less specific to supporting endocarditis as the cause of the current illness.

Question 41

The nurse increases activity for the client with an admitting diagnosis of ACS. Which client finding best supports that the client is not tolerating the activity?

Accepted Answer

Answer reason: This BP change reflects a notable fall in both systolic and diastolic pressures during activity, indicating reduced cardiac output and poor perfusion tolerance. A modest HR rise with activity can be expected, and a MAP of 80 is generally adequate for organ perfusion. Symptoms like dyspnea/diaphoresis can occur, but the clearest objective sign of not tolerating increased activity is exertional hypotension in this setting.

Question 42

The nurse is completing the client’s hospital admission history. Which statement should prompt the nurse to further question the client about symptoms associated with GERD?

Accepted Answer

Answer reason:  GERD commonly presents with retrosternal burning (heartburn) that is worse when lying flat and can awaken clients at night due to increased reflux in the supine position. This complaint cues the nurse to assess for associated reflux features such as regurgitation, sour taste, chronic cough/hoarseness, and symptom triggers (meals, alcohol, caffeine). Headaches after eating and postprandial sleepiness are not characteristic GERD symptoms and would point to other causes. Night sweats are nonspecific and raise concern for systemic conditions rather than reflux.

Question 43

The nurse is performing an initial postoperative assessment on the client following upper GI surgery. The client has an NG tube to low intermittent suction. To best assess the client for the presence of bowel sounds, which intervention should the nurse implement?

Accepted Answer

Answer reason: Bowel sounds are relatively soft and can be obscured by external noise sources during abdominal assessment. Continuous or intermittent NG suction can create audible gurgling and movement of air/fluid through the tubing that may be mistaken for intestinal peristalsis. Temporarily stopping suction helps prevent a false-positive assessment and improves the accuracy of determining whether bowel motility is present postoperatively. Using the diaphragm (not the bell) is standard for higher-pitched bowel sounds, and the exact starting quadrant is less important than obtaining an unobstructed, reliable auscultation.

Question 44

When assessing a burn victim’s skin the nurse notices the entire right and left upper extremities are red, moist, weeping, and blistered. How should the nurse document the degree and total body surface area (TBSA) burned?

Accepted Answer

Answer reason: Using the adult Rule of Nines, each entire upper extremity (arm) accounts for 9% TBSA, so both arms equal 18% TBSA. A first-degree burn would be erythematous and painful without blisters or weeping, and full-thickness burns are typically dry/leathery with impaired sensation. Therefore documentation should specify partial-thickness burns involving 18% TBSA.

Question 45

A college student visits a campus health service reporting knee pain, clicking when walking, “locking,” and “giving way” of the affected knee. The injury occurred when twisting the knee wrong during a tennis match. The nurse should further assess for which problem?

Accepted Answer

Answer reason: Meniscal injuries commonly produce joint-line pain and intermittent locking/catching during ambulation as the torn fragment impedes normal motion. Ligament injuries more often present with instability during stress (e.g., varus for LCL) rather than true locking, and patellar fractures typically follow direct trauma with marked anterior knee pain and impaired active extension. Therefore, focused assessment should prioritize signs consistent with internal derangement of the meniscus.

Question 46

The client with PD has a new surgically implanted DBS. After the stimulator is operational, which criterion should the nurse use to evaluate that the DBS is effective?

Accepted Answer

Answer reason: DBS for Parkinson disease is used to reduce motor symptoms (especially tremor, and often rigidity/bradykinesia) by modulating abnormal basal ganglia circuitry. An effective response is demonstrated by measurable improvement in the targeted motor manifestations after the device is activated. Ongoing cogwheel rigidity would indicate persistent parkinsonian motor findings rather than improvement. Facial pain relates more to trigeminal neuralgia treatments, and auras/headache patterns are more consistent with migraine/seizure-related issues, not PD DBS outcomes.

Question 47

The client tells the nurse, “I have something under my upper eyelid and don’t recall how it happened.” The client has no eye redness or pain and no changes in vision. Which intervention should the nurse implement?

Accepted Answer

Answer reason: A suspected foreign body under the upper lid is commonly identified by inspecting the palpebral conjunctiva, which requires upper-lid eversion. The absence of pain, redness, and visual change supports a non-penetrating superficial irritation where assessment to locate/remove a particle is the priority. Immediate prolonged irrigation is most indicated for chemical exposure or when particulate matter cannot be identified/removed, not as the first step when a foreign body is specifically suspected under the lid. Routine patching is not recommended because it can trap debris and increases infection risk if there is an occult corneal abrasion.

Question 48

While caring for the small-for-gestational-age newborn (SGA), the nurse notes slight tremors of the extremities, a high-pitched cry, and an exaggerated Moro reflex. In response to these assessment findings, what should be the nurse’s first action?

Accepted Answer

Answer reason: SGA newborns are at high risk for hypoglycemia due to limited glycogen and fat stores and higher metabolic demands. Tremors/jitteriness, high-pitched cry, and increased startle/Moro response are classic early neuro signs of low glucose that require immediate bedside verification. Checking glucose is the fastest, most targeted first nursing action and directly guides urgent feeding or IV dextrose interventions. Temperature assessment is important, but these findings more strongly indicate hypoglycemia than isolated cold stress; notifying the provider comes after obtaining the critical assessment data, and documentation should not delay evaluation.

Question 49

Twenty-four hours post—vaginal delivery, the postpartum client tells the nurse that she is concerned because she has not had a bowel movement (BM) since before delivery. Which action should be taken by the nurse?

Accepted Answer

Answer reason: A postpartum client may have decreased bowel motility from hormonal shifts, perineal discomfort, analgesics, dehydration, and reduced activity, so a focused GI assessment helps determine severity and need for treatment. Immediate provider notification is not indicated for an isolated report at 24 hours without additional red flags (e.g., severe distention, vomiting, absent bowel sounds, signs of ileus/obstruction). Administering a laxative without first assessing can be inappropriate if there is significant distention or abnormal bowel findings; documentation alone does not address the client’s concern or ensure safe next steps.

Question 50

The 6-month-old infant being seen in the clinic has an HR of 167 bpm, RR of 65 bpm, and Spo2 of 98%. The mother states the infant gets very tired with feedings, eating approximately two ounces every four hours. Which action should be the nurse's priority?

Accepted Answer

Answer reason: Marked tachycardia and tachypnea with fatigue during feeds strongly suggest increased cardiac workload and decreased effective systemic perfusion despite a normal oxygen saturation. A focused cardiac assessment can quickly identify a pathologic murmur or other abnormal findings that guide urgent referral and management. Capillary refill is useful but is a less specific first step for the likely underlying cause in this presentation, and attempting a feeding trial could worsen fatigue and respiratory distress.

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