Question 1

The nurse is caring for the pediatric client who was diagnosed with AIDS. Which assessment findings should alert the nurse to the development of Pneumocystis carinii pneumonia (PCP)?

Accepted Answer

Answer reason: These findings signal early respiratory compromise and should prompt rapid assessment of oxygenation and further evaluation. Another option describes oral thrush with odynophagia/dysphagia, which is a mucosal Candida infection rather than a pneumonia. Skin purple-blue lesions are more consistent with Kaposi sarcoma and do not specifically indicate PCP.

Question 2

The nurse is reviewing the medical record of the school-aged child with AGN and finds that the child has proteinuria on UA and an elevated serum BUN, creatinine, and uric acid levels. The child has had an elevated BP and low urine output for 24 hours. What should the nurse do first?

Accepted Answer

Answer reason: Acute glomerulonephritis with sustained hypertension and oliguria places the child at risk for hypertensive encephalopathy and increased intracranial pressure, which can rapidly become life-threatening. The immediate priority is to assess for neurologic compromise (e.g., headache, confusion, irritability, visual changes, seizures) to determine urgency and guide escalation of care. Simply increasing oral fluids can worsen fluid overload and hypertension in the setting of impaired renal filtration. Notifying the provider and documenting are important, but a focused neuro assessment is the most urgent first action to identify imminent complications and support timely intervention.

Question 3

A client with no history of cardiovascular disease comes to the ambulatory clinic with flu-like symptoms. The client suddenly complains of chest pain. What is the most important question for the nurse to ask the client?

Accepted Answer

Answer reason:  Chest pain requires rapid, focused assessment to distinguish potentially life-threatening cardiac ischemia from other causes (e.g., pulmonary, musculoskeletal, GI). An open-ended pain description elicits key diagnostic features such as location, quality (pressure, burning, sharp), radiation, onset, duration, and associated symptoms (dyspnea, diaphoresis, nausea), which immediately guides urgency and next actions. In contrast, asking only about pleuritic worsening or numeric intensity narrows the assessment too early and may miss classic ischemic descriptors. History of similar pain is useful but is less urgent than characterizing the current episode to identify red flags and trigger emergency response if indicated.

Question 4

A nurse has instructed a client to accurately measure the circumference of both calves each morning and to report any increase in size. The nurse determines that teaching has been effective when the client makes which statement?

Accepted Answer

Answer reason:  Accurate serial limb measurements require a consistent, objective tool to detect subtle changes that can signal worsening edema, venous thrombosis, or compartment-related swelling. A measuring tape provides a reproducible method to track circumference and compare day-to-day trends. Teaching is not effective if the client believes only large side-to-side differences matter, because an increase in either limb or gradual change over time can be clinically important. Measurement must also be taken at the same anatomic location each time, so implying it can be done “either” location reflects inconsistent technique.

Question 5

A client is admitted with Parkinson’s disease. The client’s face is expressionless, and the client’s speech is monotone. Which of the following observations by the nurse is most accurate?

Accepted Answer

Answer reason: Parkinson’s disease commonly causes hypomimia (mask-like facies) and hypophonia/monotone speech due to bradykinesia and rigidity affecting facial and laryngeal muscles. These findings can make a patient appear flat or disengaged even when cognition and mood are intact, so the nurse should interpret them as expected motor manifestations rather than psychopathology. Assuming depression and isolating the patient is unsafe and nontherapeutic, and dementia cannot be concluded from these isolated signs. Antipsychotic adjustment would be considered only with a relevant medication history or extrapyramidal adverse effects, which is not provided here.

Question 6

The nurse is caring for a client who had a chest tube inserted for treatment of a pneumothorax. Which assessment finding best indicates to the nurse that a chest tube is no longer needed?

Accepted Answer

Answer reason: The key principle is that the water-seal chamber reflects ongoing air movement from the pleural space; when the air leak and intrapleural air are resolved, there should be no tidaling once the lung is fully re-expanded and stable. Absence of fluctuation when suction is off suggests the pleural pressure changes are no longer transmitted through the system, consistent with resolution of the pneumothorax and no ongoing air leak. Minimal drainage alone is not the best indicator for pneumothorax management because the primary issue is air, not fluid. ABGs can support oxygenation status but do not directly confirm cessation of pleural air leak or readiness for chest tube discontinuation, and removing the tube to “test” breathing is unsafe and not an assessment finding.

Question 7

When obtaining information about a child, which comment made by a parent to the nurse would indicate the possibility of hypopituitarism in a child?

Accepted Answer

Answer reason: " Hypopituitarism in children commonly causes growth hormone deficiency, leading to slowed linear growth and delayed physical size changes. A parent noticing that clothing gets worn out without needing larger sizes suggests poor growth velocity over time. In contrast, needing bigger clothing every couple of months indicates normal or accelerated growth rather than endocrine growth failure. Disproportionate changes in shirt versus pant sizes suggests body proportion or pubertal pattern differences, which is less characteristic than global slowed growth from pituitary hormone deficiency.

Question 8

A family that recently went camping brings their child to the clinic with a complaint of a rash after a tick bite. Lyme disease is suspected. The nurse would assess the child for which finding?

Accepted Answer

Answer reason: This finding reflects localized infection with Borrelia and is a key assessment clue in a child with recent outdoor/tick exposure. A necrotic-centered lesion suggests other arthropod-related syndromes (e.g., necrotic arachnidism) rather than Lyme. Linear papules/vesicles in 1–3 days is more consistent with allergic contact dermatitis (e.g., poison ivy), not a tick-borne bacterial infection.

Question 9

A student nurse is having difficulty determining the liver span of a client. The experienced nurse educates the student?

Accepted Answer

Answer reason: Liver span is assessed by percussion to identify the superior and inferior borders of liver dullness along a consistent anatomic landmark. Percussing down from the right lung resonance to dullness locates the upper border, and percussing upward from abdominal tympany to dullness locates the lower border, allowing measurement between the two points. This method is standardized (midclavicular line) and is more reliable than starting with palpation, which may not detect a normal liver edge. The claim that measurement has little value is incorrect because changes in span can indicate hepatomegaly or atrophy, and knee flexion may aid comfort but does not teach the correct measurement technique.

Question 10

The client has sustained a traumatic brain injury (TBI) secondary to a motor vehicle accident. Which signs/symptoms would the emergency department (ED) nurse expect the client to exhibit?

Accepted Answer

Answer reason: Traumatic brain injury commonly produces acute neurologic deficits plus symptoms of concussion or increased intracranial pressure. Visual changes and nausea/vomiting are classic early findings after head injury, and focal motor weakness (e.g., hemiparesis) can occur with cerebral contusion, hemorrhage, or edema affecting motor pathways. The other choices emphasize findings more consistent with spinal cord injury/autonomic dysreflexia, meningitis/meningeal irritation, or unrelated bedside glucose testing rather than typical TBI presentation. Therefore, the option combining concussion-type symptoms with a focal deficit best matches expected ED findings.

Question 11

The nurse is caring for a client who has a C-6 vertebral fracture and is using Crutchfield tongs with 2-pound weights. Which data would the nurse expect the client to exhibit?

Accepted Answer

Answer reason: A cervical spinal cord injury can disrupt ascending sensory pathways, producing sensory deficits below the level of injury; ongoing neuro checks are therefore expected in a client managed with cervical traction. With a C6-level injury, sensation is commonly impaired below that dermatome due to cord involvement and edema, and monitoring for this is a key nursing assessment. Controlled mechanical ventilation is more typical with high cervical injuries (around C1–C4) affecting the diaphragm via the phrenic nerve. Motor findings and reflex changes can vary with the completeness and phase of injury (spinal shock vs later hyperreflexia), making them less reliably “expected” than a below-level sensory loss in a C6 fracture with suspected cord compromise.

Question 12

A client is using a leaf blower near an old campfire. Glass debris from a broken bottle flies everywhere. The client comes to the emergency room complaining of a foreign body sensation in his right eye, watery eyes, and photophobia. Which nursing action takes priority?

Accepted Answer

Answer reason: Baseline functional assessment is the priority in suspected ocular trauma because it guides urgency, documents status before interventions, and helps detect vision-threatening injury. Measuring visual acuity is quick, noninvasive, and should be done before manipulating the eye or applying medications. Everting the eyelid or examining for a foreign body can worsen injury if there is an embedded object or corneal penetration, and should follow initial assessment with appropriate precautions. An eye shield may be indicated if penetration is suspected, but acuity is still the first priority assessment unless the globe is obviously ruptured.

Question 13

The nurse is recording an electrocardiogram (ECG) for a client with a pacemaker in the cardiac clinic. He has had the fixed-rate pacemaker for many years and states that at times he feels funny and gets nauseated. The nurse interprets which ECG pattern as possible pacemaker malfunctionation?

Accepted Answer

Answer reason: Spikes occurring at varying points in the cycle indicate the pacemaker is not reliably sensing native beats and is firing when it should be inhibited. In contrast, a ventricular paced beat commonly shows a pacing spike followed by a wide QRS complex and can be a normal expected finding. Short T waves and absent P waves are not specific indicators of pacemaker device dysfunction.

Question 14

A 28-year-old male client complaining of a racing heart and nervousness is admitted to the telemetry floor. His telemetry shows a heart rate of 130 beats/minute in sinus tachycardia. His skin is very warm and dry, and his eyes appear to be bulging. Which nursing action is the most important upon admission?

Accepted Answer

Answer reason: Palpating the anterior neck assesses for thyroid enlargement or nodules (goiter), supporting rapid identification of an endocrine cause of the dysrhythmia and guiding prompt provider notification and treatment planning. This assessment is directly relevant to the suspected condition and can be done immediately without delaying care. By contrast, urinary catheterization and gait observation do not address the likely underlying cause or immediate physiologic risk associated with uncontrolled thyroid hormone excess.

Question 15

While the nurse is assessing the client hospitalized with recurrent lower-extremity cellulitis, the client states, “I have athlete’s foot; do you want to check it?” The nurse concludes that this information is significant for what reason?

Accepted Answer

Answer reason: Breaks in skin integrity create portals of entry for bacteria such as streptococci and staphylococci, which are common causes of cellulitis. Interdigital fissures and maceration from tinea pedis provide exactly this compromised barrier, making recurrent lower-extremity cellulitis more likely. Addressing the fungal infection and restoring intact skin helps reduce recurrence risk by removing the underlying predisposing factor. A common distractor is assuming cellulitis is fungal; in most cases it is a bacterial infection requiring systemic antibiotics rather than topical antifungals alone.

Question 16

The nurse is concerned that a very dark-skinned African American client may be developing a pressure ulcer on the heel. What should the nurse do to assess for the presence of tissue injury?

Accepted Answer

Answer reason: In darkly pigmented skin, early pressure injury may not present as visible erythema, so comparing color changes to adjacent tissue is a key assessment strategy. Nonblanchable redness is difficult to assess reliably in very dark skin, making the blanch test less useful and potentially misleading. Early injury can appear as persistent discoloration (often darker), and nurses should also consider other cues (temperature, firmness, pain), but the question asks specifically what to do to assess for tissue injury in this context. Simply increasing room lighting does not address the primary challenge of altered visual presentation in darkly pigmented skin.

Question 17

The nurse is caring for the client who is having difficulty walking. Which procedure should the nurse procedure to test the cerebellar function of the client?

Accepted Answer

Answer reason: Cerebellar function is primarily assessed by coordination and rapid alternating movements, which reveal dysdiadochokinesia when impaired. This maneuver directly tests the ability to perform quick, rhythmic, alternating motions in a controlled way. Option A assesses sensory discrimination (sharp/dull), not cerebellar coordination. Option C evaluates muscle strength, which can be abnormal with motor pathway disease even when coordination testing is the key need for suspected cerebellar dysfunction.

Question 18

While assessing the postpartum client who is 10 hours post—vaginal delivery, the nurse notes a perineal pad that is totally saturated. To determine the significance of this finding, which question should the nurse ask the client first?

Accepted Answer

Answer reason:  A saturated perineal pad can represent normal lochia if it accumulated over several hours or can signal postpartum hemorrhage if it soaked quickly. The first step is to quantify bleeding by establishing the time interval since the last pad change, which determines rate of blood loss and urgency of intervention. This question rapidly clarifies whether the finding reflects excessive bleeding (e.g., soaking a pad in

Question 19

The nurse assesses the pain level of the Native American pediatric client recovering from cardiac surgery. Knowing that Native American pediatric clients may not express pain, the nurse reviews the child's pulse and BP readings following analgesic administration. Which finding indicates that the client's pain is not well controlled?

Accepted Answer

Answer reason: When a child may underreport pain, these physiologic stress indicators become important objective cues that analgesia is inadequate. A pattern of lower heart rate and/or lower blood pressure would be more consistent with relief, sedation, or other causes rather than persistent pain. Therefore, the finding that best signals poor pain control after analgesic administration is simultaneous tachycardia and hypertension.

Question 20

The nurse is interpreting an ECG rhythm strip for the 2-year-old child with a congenital heart defect. The measurement for the PR interval is 0.26 seconds; the QRS is 0.08 seconds, and the QT is 0.28. The ventricular rate is 126 bpm. How should the nurse document the child’s rhythm?

Accepted Answer

Answer reason: 20 seconds) with otherwise normal conduction. The child’s PR interval is 0.26 seconds, meeting criteria for first-degree AV block, while the QRS duration of 0.08 seconds argues against bundle branch block (which would widen QRS). A ventricular rate of 126 bpm in a 2-year-old falls within the tachycardic range for age rather than bradycardia. Therefore, the most accurate documentation combines sinus tachycardia with first-degree AV block.

Question 21

The adolescent is hospitalized with a tentative diagnosis of Addison’s disease. Which nursing assessment findings would support the diagnosis of Addison’s disease?

Accepted Answer

Answer reason: Aldosterone deficiency produces sodium loss and volume depletion, which commonly manifests as salt craving. Low adrenal androgens can reduce pubic and axillary hair, and chronic cortisol deficiency contributes to nonspecific neuropsychiatric symptoms such as irritability and fatigue. Distractors include features inconsistent with Addison’s (e.g., hypopigmentation or weight gain/hirsutism suggesting other endocrine disorders rather than adrenal insufficiency).

Question 22

The nurse is planning care for children diagnosed with IBD. After collecting and analyzing the information about the clients, the nurse makes which statement that best reflects the conclusion about the information?

Accepted Answer

Answer reason: This item tests the nurse’s ability to synthesize client data patterns to draw an overall conclusion, which is part of clinical assessment reasoning. A broad statement describing the predominant demographic across both IBD diagnoses best reflects an analysis of a grouped data set rather than an absolute claim about a subset. Options using absolute language like “all” or “none” are typically incorrect unless every record supports it. The diarrhea severity comparison is also unreliable as a general conclusion because bloody diarrhea is more classically prominent in ulcerative colitis, and severity varies by individual.

Question 23

The nurse is caring for the infant who has respiratory distress and copious oral secretions. Which finding would prompt the nurse to notify the HCP with a concern about possible tracheoesophageal atresia (TEA)?

Accepted Answer

Answer reason: TEA/esophageal atresia is suspected when a feeding/OG tube cannot be advanced into the stomach because the esophagus ends in a blind pouch, leading to coiling and resistance. This anatomic blockage also explains the infant’s excessive oral secretions and respiratory distress from aspiration. A decrease in distress with suctioning can occur in many airway/secretions problems and is not specific for TEA. Abdominal findings and gastric aspirate color are less direct than the classic inability to pass an OG/NG tube.

Question 24

The nurse is educating the parent of the male infant with phimosis. Which statement should the nurse include in teaching?

Accepted Answer

Answer reason:  Phimosis is a tight preputial opening that can intermittently impede urinary outflow, so parents should be taught to recognize abnormal voiding patterns such as weak/dribbling stream or ballooning of the foreskin. Forceful or routine daily retraction in infants is not recommended because the foreskin is commonly nonretractable normally and can tear, increasing risk of pain, bleeding, and infection. Testicular enlargement from fluid accumulation is not a typical teaching point for phimosis (more consistent with hydrocele/inguinal issues). Predicting permanent inability to void a straight stream is inaccurate and alarmist; many cases improve with growth or appropriate treatment.

Question 25

A client tells the nurse that she experiences pain and numbness in the fingers when typing on a computer keyboard. Which action will help the nurse assess for Phalen’s sign?

Accepted Answer

Answer reason: Sustained wrist flexion with the backs of the hands pressed together for up to 60 seconds reproduces paresthesia or pain in the median-nerve distribution if the test is positive. This directly matches the described action and is appropriate for a client with typing-related finger numbness. A common distractor is gentle tapping over the median nerve, which assesses Tinel’s sign rather than Phalen’s. Resisted wrist extension and arm elevation do not specifically stress the carpal tunnel in the characteristic way used to elicit this sign.

Question 26

The nurse is evaluating an arterial blood gas result from a client with a subdural hematoma and notes the PaCO2 is 30 mm Hg. How does the nurse interpret this result?

Accepted Answer

Answer reason: In acute intracranial pathology, a modest reduction in PaCO2 may be an intentional, time-limited measure to help control rising ICP while definitive management occurs. This value is not normal (typical PaCO2 ~35–45 mm Hg), so dismissing it is incorrect. It also does not indicate hypoventilation, which would raise PaCO2, and the stem provides no evidence of oxygenation failure requiring aggressive hyperventilation.

Question 27

The nurse is teaching the parents of a child newly diagnosed with diabetes to identify the signs and symptoms of hypoglycemia. Which response by the parents indicates the teaching has been effective?

Accepted Answer

Answer reason: Hypoglycemia triggers adrenergic and neuroglycopenic responses, producing early symptoms such as tremors, hunger, irritability, headache, and dizziness. Recognizing these warning signs is critical so caregivers can promptly check blood glucose and treat with fast-acting carbohydrate before progression to confusion, seizures, or loss of consciousness. The other options describe findings more consistent with dehydration/hyperglycemia (e.g., decreased urine output or urinary frequency) or nonspecific gastrointestinal complaints rather than classic low-glucose manifestations. This parent statement correctly identifies the typical symptom cluster nurses teach for low blood glucose in children with diabetes.

Question 28

An infant is brought into the emergency room after an apneic episode. It is later determined to be an apparent life-threatening event (ALTE). What statement is incorrect regarding ALTE?

Accepted Answer

Answer reason: ALTE/BRUE describes a sudden, frightening episode (e.g., apnea, color change, altered tone) that is usually self-limited or resolves with intervention, but it is not proven to cause SIDS. The key clinical concept is that ALTE may prompt evaluation for underlying problems (reflux, seizure, infection, airway issues), yet most infants do not go on to have SIDS and the relationship is associative rather than causal. Features like limpness and color change are classic components of an ALTE presentation. Episodes may require stimulation/resuscitation by caregivers, which is part of why the event is considered life-threatening.

Question 29

The home health nurse is caring for a client diagnosed with Parkinson disease. Which comment by the client’s significant other would suggest a common cognitive problem associated with Parkinson disease?

Accepted Answer

Answer reason:  Parkinson disease is associated with cognitive changes ranging from mild cognitive impairment to Parkinson disease dementia, often affecting attention, executive function, and memory for day-to-day tasks. Increasing forgetfulness about routine activities is a common, non-psychotic cognitive symptom and should prompt further assessment of cognition and safety at home (medication management, driving, falls). In contrast, marked suspicion that medications are poisoned suggests psychosis/paranoia, which can occur but is less “common” than general cognitive slowing/forgetfulness and is often medication-related. The other statements more closely reflect mood/relationship distress or possible apathy/depression rather than a primary cognitive deficit.

Question 30

Nurse researchers have determined that central venous pressure (CVP), pulmonary artery pressure (PAP), and pulmonary artery wedge pressure (PAWP) can be reliably measured at head-of-bed positions. From which position can these pressures be accurately measured?

Accepted Answer

Answer reason: Hemodynamic pressures are accurate only when the transducer is leveled to the phlebostatic axis and patient positioning is kept consistent, because changes in torso angle and body orientation alter hydrostatic pressure effects on the catheter–transducer system. Standard practice allows reliable CVP/PAP/PAWP measurements in the supine position with the head of bed anywhere from flat to about 60 degrees as long as the reference level is maintained. Prone positioning is not used for routine, accurate PA catheter pressure measurement because it disrupts consistent leveling/reference and may alter intrathoracic mechanics. Higher angles (60–90 degrees) introduce greater postural effects and are less reliable for trending compared with the accepted 0–60 degree range.

Question 31

The client voided 300 mL after having an indwelling urinary catheter removed six hours ago. A bladder scan immediately after the void showed that the client has a postvoid residual (PVR) volume of 250 mL. What should the nurse conclude from this finding?

Accepted Answer

Answer reason: A postvoid residual assesses how well the bladder empties, and elevated residual urine indicates urinary retention. A PVR of 250 mL is markedly above typical acceptable thresholds (generally

Question 32

A client on a cardiac monitor has a heart rate of 170 beats/minute, with frequent premature contractions. Which nursing action is best?

Accepted Answer

Answer reason: The key principle is to validate monitor findings by promptly assessing the patient for hemodynamic stability and symptoms before escalating or delegating care. A rapid in-person assessment (LOC, airway/breathing, pulse/BP, chest pain, dyspnea, skin signs, oxygenation, rhythm confirmation) determines whether this is an artifact versus a life-threatening dysrhythmia needing emergency response. Calling the provider may be necessary next, but doing so without immediate patient assessment can delay recognition of instability and appropriate urgent interventions (e.g., oxygen, IV access, defibrillator readiness). Delegating vitals to assistive personnel is inappropriate because new tachycardia with ectopy requires RN-level clinical judgment and continuous evaluation. Notifying a supervisor does not address the immediate physiologic risk and is not the priority action.

Question 33

A nurse is assisting in monitoring a client in labor. Which monitoring data are indicative of fetal well-being?

Accepted Answer

Answer reason: A baseline of 145–155 bpm is normal (110–160) and a ≥15 bpm acceleration lasting ≥15 seconds is a reassuring finding at term. Late decelerations are associated with uteroplacental insufficiency and are not reassuring even if the baseline rate is normal. Variable decelerations suggest umbilical cord compression; when decelerations are significant (e.g., to 90), they are not the best indicator of well-being compared with accelerations.

Question 34

The nurse is assessing a client with head trauma. The nurse notes a urine output of 300 mL/hour, dry skin, dry mucous membranes, and a high serum sodium. The most important intervention for the nurse to implement would be?

Accepted Answer

Answer reason: Head trauma with profound polyuria plus dehydration signs and hypernatremia most strongly suggests diabetes insipidus from impaired ADH secretion. The priority nursing action is to further assess and trend urine concentration to confirm excessive free-water loss; low urine specific gravity supports DI and guides urgency of fluid and hormone replacement. Renal failure would typically reduce urine output rather than cause marked dilute polyuria, making that distractor inconsistent. Slowing IV fluids could worsen hypernatremic dehydration, and skin emollients are non-urgent compared with identifying and addressing the cause of water loss.

Question 35

The nurse working in the telemetry unit notices a premature ventricular contraction (PVC) on the client’s monitor. While assessing the client, he states that he felt something “flip flop” in his chest. There are no other PVCs noted in the following hour. The nurse would make which documentation?

Accepted Answer

Answer reason: One PVC was observed on monitor between 1:00 and 2:00 p.m. today. The client stated that he felt a “flip flop” in his chest. No changes in vital signs and no complaints of chest pain or shortness of breath. Nursing documentation should be objective, time-specific, and include the rhythm event, the patient’s subjective symptoms, and the associated assessment findings that reflect clinical stability or deterioration. This option captures the exact observation window, the client’s reported sensation, and key negative findings (no vital-sign changes, no chest pain, no dyspnea) that help establish the significance of an isolated PVC. It also demonstrates appropriate monitoring by linking the dysrhythmia to patient assessment rather than ECG interpretation alone. By contrast, rhythm-description-only notes omit the patient response, and vague statements do not provide enough detail to support clinical decision-making or trend monitoring.

Question 36

The nurse is assessing a newly admitted client who is diagnosed with hypocalcemia. In order to assess the thyroid gland properly, which of the following techniques would the nurse use?

Accepted Answer

Answer reason: Thyroid assessment relies on palpation while the gland moves with swallowing because it is attached to the trachea and laryngeal structures. Slight neck flexion relaxes the anterior neck muscles and improves the examiner’s ability to feel thyroid size, symmetry, and nodules as the tissue elevates during a swallow. Turning slightly toward the side being examined helps expose the targeted lobe by easing sternocleidomastoid tension. Maneuvers like coughing, deep inhalations, hyperextension, or “massaging” the neck do not appropriately mobilize the thyroid for palpation and can interfere with accurate findings.

Question 37

The nurse is reviewing information for the client with type 1 DM. The nurse concludes that the client may be experiencing the Somogyi phenomenon, as evidenced by which finding?

Accepted Answer

Answer reason: The key pattern is a low 0200–0300 glucose followed by elevated fasting/morning glucose. This option shows clear nighttime hypoglycemia with markedly high morning values, matching the rebound pattern. By contrast, elevated 0200 glucose with elevated morning glucose is more consistent with insufficient basal insulin or the dawn phenomenon rather than nocturnal hypoglycemia.

Question 38

The mother of the 12-year-old with type 1 DM asks the nurse whether changes in the daily routine are needed during her child’s 4-week attendance at summer camp. Which is the best response by the nurse?

Accepted Answer

Answer reason:  In type 1 diabetes, insulin dosing and carbohydrate intake must be adjusted to match changes in activity to prevent hypoglycemia. Camp typically increases physical exertion, so additional carbohydrates (and/or insulin adjustment) may be needed based on glucose trends. Frequent self-monitoring several times daily is essential to evaluate the effect of activity and meals and guide safe adjustments. Statements that presume insulin will increase due to camp food or use fixed percentage changes are unsafe because they ignore individual variability and activity-related glucose drops.

Question 39

During a clinic visit, the parent states to the nurse, “When taking pictures of my baby using the camera flash, I see a red coloration to my baby’s left eye, but the right eye has a white reflection. Is this normal?” Which response by the nurse is correct?

Accepted Answer

Answer reason: “It is good that you mentioned this. After examining your baby’s eyes, we can discuss what the white reflection may suggest.” A white pupillary reflex (leukocoria) in photos is an abnormal finding that can indicate serious ocular pathology and warrants prompt assessment. This response appropriately acknowledges the concern, prioritizes focused eye examination (including red reflex evaluation), and prepares the parent for discussion of potential implications without providing false reassurance. Option A incorrectly normalizes leukocoria, which can delay diagnosis of conditions such as retinoblastoma or congenital cataract. Option D is therapeutic but incomplete because it does not address the need for immediate clinical evaluation of a potentially urgent sign.

Question 40

The parents of the 2-year-old child have myopia. They ask the nurse if their child should have a traditional eye examination because they often observe their child excessively blinking, squinting, and tearing. Which response by the nurse is correct?

Accepted Answer

Answer reason:  Vision screening and assessment must be developmentally appropriate, because very young children may not reliably cooperate with standard visual acuity testing used in older children and adults. Excessive blinking, squinting, and tearing can reflect visual strain or irritation and warrant evaluation, but the approach should use age-appropriate pediatric methods and referral rather than assuming routine adult-style testing will be definitive. Family history increases the child’s risk for refractive errors, so dismissing screening is unsafe. Statements that myopia is not inherited or that young children cannot have it are inaccurate and could delay needed assessment and intervention.

Question 41

Which statement by the nurse accurately explains the need for a client with hypertension to obtain an annual eye exam?

Accepted Answer

Answer reason:  Hypertension causes characteristic, observable microvascular damage, and the retinal vessels provide a direct “window” to assess arteriolar changes from chronic elevated blood pressure. A dilated retinal exam can detect hypertensive retinopathy findings such as arteriolar narrowing, AV nicking, hemorrhages, exudates, and papilledema, which help gauge end-organ injury and cardiovascular risk. Cornea and sclera exams do not evaluate systemic arteriolar effects of hypertension. Focusing on the fovea for venous occlusions is not the primary rationale for routine hypertension screening compared with assessing retinal arteriolar changes.

Question 42

When explaining the causes of hypothyroidism to the parents of a newly diagnosed infant, a nurse should recognize that further education is needed when the parents ask which question?

Accepted Answer

Answer reason: " Phototherapy is used to treat neonatal hyperbilirubinemia (jaundice) by altering bilirubin, not to treat low thyroid hormone levels. Congenital hypothyroidism most commonly results from thyroid dysgenesis (abnormal gland development) or defects in thyroid hormone synthesis, and management requires thyroid hormone replacement (e.g., levothyroxine) to prevent neurodevelopmental impairment. The question about “special light” reflects confusion with jaundice treatment and indicates a misunderstanding of both cause and therapy. Clarifying this misconception is critical because delayed or incorrect treatment can lead to irreversible developmental consequences.

Question 43

The 72-year—old client with a left leg DVT and a history of a brain tumor is hospitalized for 3 days. The client's care plan indicates a nursing problem of Imbalanced nutrition: less than body requirements related to poor appetite and decreased oral intake. Which assessment finding would best indicate a need to revise the care plan related to the nursing problem?

Accepted Answer

Answer reason: A care plan should be revised when objective data show the problem persists or outcomes are not being met despite interventions. Documented inadequate caloric intake after several days of hospitalization indicates the current nutrition interventions are insufficient and the plan needs changes (e.g., meal assistance, diet modification, supplements, consults). Dry/cracked mucous membranes point more toward a fluid volume issue rather than directly evaluating nutritional goal attainment. Stating no hunger is consistent with the identified etiology (poor appetite) and does not by itself show that the plan is failing unless intake data confirm inadequate nutrition.

Question 44

A 75-year-old client exhibits diminished but equal peripheral pulses and cool hands and feet. The nurse's most appropriate action is to?

Accepted Answer

Answer reason: Aging commonly leads to decreased cardiac contractility and increased arterial stiffness, which can reduce peripheral perfusion and make extremities feel cool with weaker pulses. Equal, symmetric pulse diminution suggests a generalized age-related change rather than an acute unilateral arterial occlusion or embolus. With no signs of instability provided (e.g., chest pain, syncope, hypotension, altered mental status), escalation such as calling a code team or urgent monitoring for heart block is not the best first response. The safest nursing judgment here is to recognize expected gerontological findings while continuing routine assessment for any new red flags.

Question 45

When caring for a patient who experienced a head injury in a car accident, the nurse observes a bruised section behind the patient’s ear. The nurse knows that this type of marking is known as?

Accepted Answer

Answer reason:  Postauricular ecchymosis after head trauma is a classic physical assessment finding suggesting a basilar skull fracture, reflecting bleeding tracking to the mastoid region. This assessment cue is important because it signals high risk for complications such as CSF leak and intracranial bleeding, prompting urgent escalation and avoidance of procedures like nasotracheal suctioning or NG tube insertion. The other options refer to unrelated bedside findings: facial nerve twitching with hypocalcemia, an eponym not used for this presentation, and calf pain with dorsiflexion historically associated with DVT. Recognizing this sign supports timely monitoring and diagnostic evaluation in head-injured patients.

Question 46

A client requires blood pressure measurements every 30 minutes. Which of the following actions should the nurse implement when using an electronic blood pressure device?

Accepted Answer

Answer reason: The core principle is to validate automated readings with an accurate baseline and confirm proper cuff sizing/placement, since oscillometric devices can be less reliable with arrhythmias, shivering, movement, or poor perfusion. An initial manual measurement establishes the client’s true BP and allows comparison if subsequent electronic readings appear inconsistent or trigger alarms. Placing a cuff over clothing can falsely elevate readings and is not recommended. Setting a fixed diastolic alarm limit (e.g., 65 mm Hg) is not individualized and may miss clinically important hypotension or create nuisance alarms; skin checks are important but the key initial action is establishing an accurate baseline.

Question 47

The ICU is caring for a client in heart failure who recently had a central venous catheter (CVC) placed for medication administration and central venous pressure (CVP) monitoring. As the nurse connects the transducer to the monitor, the current reading is 100 mmHg. Which action should the nurse perform first?

Accepted Answer

Answer reason:  A CVP value of 100 mmHg is physiologically implausible and strongly suggests a setup/measurement error (e.g., transducer not zeroed/leveled, tubing issue, wrong scale/units), so the nurse should first validate the equipment and waveform/reading. Troubleshooting the monitoring system is the safest first step before acting on potentially false data that could lead to inappropriate interventions. After correcting obvious device issues (reset/re-zero/verify connections and calibration), persistent abnormal readings warrant using an alternate method/technology to confirm accuracy. Calling the provider immediately or documenting the number without verification risks acting on artifact rather than the patient’s true hemodynamic status.

Question 48

While assessing a postpartum client, the nurse extends the client’s leg and dorsiflexes her foot. The client asks why the nurse is doing this. The nurse’s best response is that this maneuver?

Accepted Answer

Answer reason: This assessment is based on screening for deep vein thrombosis, a postpartum complication related to hypercoagulability and venous stasis. Forced dorsiflexion with the leg extended is the classic maneuver historically associated with calf discomfort suggestive of a clot. While it is neither sensitive nor specific enough to rule in/out DVT, among the options it is the only one that matches the purpose of the maneuver. The other choices describe uterine or musculoskeletal goals that are not evaluated by dorsiflexion of the foot.

Question 49

An adult client on the surgical floor has tachycardia, tachypnea, and a slight temperature elevation. The client is sitting at a 90-degree angle and reports severe shortness of air. Which assessment does the nurse perform first?

Accepted Answer

Answer reason: Auscultating breath sounds rapidly evaluates ventilation and can identify urgent problems such as bronchospasm, atelectasis, pulmonary edema, or pneumothorax in a post-surgical patient. This finding directly guides immediate escalation (oxygen delivery changes, rapid response activation, or urgent provider notification) and targeted interventions. Cardiac and perfusion checks are important, but they do not address the most immediate threat when the primary complaint is respiratory distress.

Question 50

A nurse is caring for a client diagnosed with pneumonia. Which assessment finding would indicate a potential complication of pneumonia?

Accepted Answer

Answer reason: Pneumonia can impair gas exchange and increase work of breathing, so early clinical deterioration is often reflected by tachypnea. A respiratory rate of 24/min is abnormal and suggests worsening respiratory status and risk for complications such as hypoxemic respiratory failure or sepsis-related respiratory compromise. In contrast, an oxygen saturation of 98% on room air indicates adequate oxygenation at that moment. Fever is common in uncomplicated pneumonia and, by itself, is less specific for a complication than an increasing respiratory rate. Normal blood pressure does not suggest an evolving complication.

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