Question 1

The nurse sees the provider documented “borborygmus” in the patient’s chart and correctly identifies this as which of the following findings?

Accepted Answer

Answer reason: This corresponds to increased bowel activity noted on auscultation. It is commonly heard with conditions like gastroenteritis, early bowel obstruction, or after eating, where motility is heightened. In contrast, hypoactive or absent sounds suggest decreased motility (e.g., ileus, peritonitis) rather than the noisy, rumbling pattern described.

Question 2

A nurse measures a patient's blood pressure on the right arm and notes a high reading. The nurse decides to reassess by reading on the patient's leg. This reading shows low blood pressure. What could this result indicate?

Accepted Answer

Answer reason: This obstruction reduces perfusion pressure to the legs while the arms are proximal to the narrowing and show hypertension. The arm-leg BP discrepancy is therefore a direct physiologic consequence of the lesion and is often accompanied by diminished femoral pulses and delayed capillary refill in the lower extremities. Septal defects primarily cause shunting and murmurs rather than a consistent upper-versus-lower extremity BP differential.

Question 3

The nurse performs a physical assessment on a client with heart failure (HF). The nurse documents 2+ pitting edema bilateral ankles. Which description best defines 2+ edema?

Accepted Answer

Answer reason: A 2+ grade corresponds to a moderate pit, classically about 4 mm, which is consistent with the expected finding in dependent edema from heart failure. Lower grades (e.g., 1+) are more superficial (about 2 mm) and represent milder interstitial fluid. Higher grades (e.g., 3+ to 4+) produce deeper pits (around 6–8 mm) and suggest more significant volume overload and tissue fluid retention.

Question 4

A patient with a tracheostomy is on a ventilator. Saturations drop to 90% and the ventilator alarms high pressure. What is the nurse’s priority action?

Accepted Answer

Answer reason: g., kinked circuit, mucus plug) that can quickly worsen oxygenation. The immediate nursing priority is a rapid assessment of the ventilator circuit and the patient to identify and correct a reversible mechanical problem while evaluating breath sounds for obstruction/bronchospasm or unilateral changes. Suctioning may be needed, but it should follow a quick check for kinks/disconnections and a focused respiratory assessment; additionally, prolonged suctioning time is unsafe and can worsen hypoxemia. Escalating FiO2 or preparing for a chest tube treats consequences or specific etiologies without first confirming the cause, delaying the fastest fix.

Question 5

A 6-year-old in the Emergency Department is being treated for asthma. Prior to the administration of a nebulized medicine, what is most important for the nurse to do?

Accepted Answer

Answer reason: Auscultation directly reflects airflow and bronchospasm and can reveal red flags such as markedly diminished breath sounds (“silent chest”) indicating impending respiratory failure. Oxygen saturation and heart rate are important monitoring parameters but do not replace a focused lung assessment that guides immediate care and reassessment after treatment. Capillary refill is less relevant to the primary problem (airway obstruction) unless shock is suspected.

Question 6

A nurse and nursing student are caring for a child who sustained a head injury as a result of a fall from a play structure. The nurse knows the nursing student is prepared to care for the child when the student states?

Accepted Answer

Answer reason: " Head injury monitoring prioritizes early recognition of neurologic deterioration and rising intracranial pressure, which can first present as subtle changes in vital signs and breathing pattern. Trending respirations, pulse, and blood pressure supports prompt identification of Cushing’s response and impending herniation physiology. Fixed, dilated pupils are a late and ominous sign, so waiting for that finding reflects delayed recognition. Sleepiness after head injury can be expected and must be assessed in context (arousability, LOC trends) rather than automatically triggering a call without broader neurologic/vital-sign assessment.

Question 7

A walk-in patient visits the clinic, complaining of abdominal pain and diarrhea. After taking the patient’s vital signs, which phase of the nursing process is the nurse implementing?

Accepted Answer

Answer reason: Measuring vital signs provides objective baseline information about hemodynamic status and possible dehydration or infection in a patient with abdominal pain and diarrhea. Nursing diagnosis and planning occur only after sufficient data are gathered and interpreted. Implementation would involve carrying out interventions (e.g., administering fluids/meds or initiating stool studies), not the initial data collection itself.

Question 8

A client with burns covering 50% of their body was admitted 10 hours ago and now has a blood glucose level of 142 mg/dL. What should the nurse do first?

Accepted Answer

Answer reason: The safest first nursing action is to validate an unexpected or potentially actionable bedside result (e.g., fingerstick error from poor perfusion, contamination, timing issues) before changing therapy. Stopping dextrose-containing fluids could compromise caloric needs and fluid resuscitation goals in acute burn care and is not indicated based on a single mild reading. After confirmation, the nurse can trend values and notify the provider if persistent elevation requires an insulin protocol per facility policy.

Question 9

Which information obtained by assessment ensures that the client’s respiratory efforts are currently adequate?

Accepted Answer

Answer reason: Adequate current respiratory effort is best supported by objective evidence of oxygenation and ventilation effectiveness. A pulse oximetry value in the normal range (typically about 95–100% in most adults at sea level) indicates sufficient oxygen saturation at the time of assessment. Being able to talk, being alert, or having visible chest movement can occur despite early respiratory compromise and are less specific measures of adequacy. Therefore, the oxygen saturation reading most directly supports that respiratory efforts are currently adequate.

Question 10

The nurse is measuring the client's urine output and straining the urine to assess for stones. Which of the following should the nurse record as objective data?

Accepted Answer

Answer reason: A quantified urine output is a direct measurement that can be verified and trended to evaluate renal perfusion, hydration status, and potential obstruction. The other choices are subjective because they rely on client-reported symptoms or impressions rather than nurse-measured findings. In stone monitoring, documenting exact intake/output and any observed sediment/stones provides the most defensible clinical record.

Question 11

A client is wearing a continuous cardiac monitor, which begins to sound its alarm. A nurse sees no electrocardiogram complexes on the screen. The first action of the nurse is to?

Accepted Answer

Answer reason: When a monitor shows a flat line or no complexes, the priority is to assess the patient first because equipment artifact (disconnected leads, poor contact) can mimic asystole. Immediate bedside assessment of responsiveness, breathing, and pulse determines whether this is a true life-threatening rhythm requiring emergency response. Simultaneously checking lead placement and cable connections is a rapid fix if the issue is technical, restoring accurate monitoring and preventing unnecessary escalation. Calling the provider or pressing the recorder delays essential assessment, and activating a code is only appropriate after confirming the client is pulseless/unresponsive.

Question 12

The nurse is performing a mental status examination on a male client diagnosed with a subdural hematoma. This test assesses which of the following?

Accepted Answer

Answer reason: These abilities reflect overall cortical (cerebral) functioning, which can be impaired by intracranial bleeding such as a subdural hematoma due to mass effect and increased intracranial pressure. Cerebellar testing focuses on coordination and balance, which is assessed with gait and finger-to-nose rather than cognition. Sensory function is assessed with neurologic sensory testing (e.g., light touch, pain), not primarily with mental status.

Question 13

When assessing a lesion diagnosed as malignant melanoma, the nurse most likely expects to note which of the following?

Accepted Answer

Answer reason: Malignant melanoma is most classically assessed using the ABCDE criteria, where asymmetry and border irregularity are hallmark warning signs. An irregular shape fits these screening features and raises suspicion for melanoma compared with more uniform, symmetric lesions. A pearly papule with central crater and waxy/rolled border is more consistent with basal cell carcinoma, a common distractor. A small dry, rough scaly papule is more typical of actinic keratosis, and a firm nodular crusted lesion can describe other skin cancers but is not the most characteristic melanoma descriptor among these choices.

Question 14

The nurse is assessing a multigravida, 36 weeks gestation for symptoms of pregnancy-induced hypertension and preeclampsia. The nurse should give priority to assessing the client for?

Accepted Answer

Answer reason: New or worsening facial/periorbital swelling is a more concerning finding than dependent ankle edema, which can be common in normal late pregnancy. Diminished reflexes are not a typical preeclampsia warning sign (hyperreflexia and clonus suggest severe disease and seizure risk). Pulse deficits are not a hallmark assessment finding for pregnancy-induced hypertension/preeclampsia compared with edema in the face/hands and other severe-feature symptoms.

Question 15

The primary healthcare provider (PHCP) is caring for a client with a neurologic injury who wants to perform a Romberg test. The nurse should instruct the client that this test will require?

Accepted Answer

Answer reason: The Romberg test evaluates balance by assessing proprioception and vestibular function when visual input is removed. The client is positioned standing upright with feet together and arms at the sides, then asked to close the eyes while the examiner observes for swaying or loss of balance. Flexing the neck assesses cervical range/meningeal irritation rather than balance. The heel-to-shin maneuver is a cerebellar coordination test, not the Romberg test, which primarily isolates sensory ataxia when vision is eliminated.

Question 16

The nurse is returning a patient from the bathroom when the patient reports dizziness and shortness of breath. The nurse returns the patient to the bed to rest. What is the nurse’s priority?

Accepted Answer

Answer reason: Measuring vital signs (including SpO2 if available) is the fastest way to quantify severity, identify immediate threats, and guide next actions such as oxygen, notifying the provider/rapid response, or further cardiac/respiratory assessment. Providing a bedpan or commode addresses comfort/elimination but does not evaluate the potentially unstable condition. A defibrillator is appropriate only if the patient is pulseless/unresponsive or in a shockable rhythm; the presented scenario supports assessment first.

Question 17

A client scheduled for left femoral popliteal bypass graft has signs of chronic poor perfusion to the left lower extremity. Which action is most important for the nurse to complete before the procedure?

Accepted Answer

Answer reason: Peripheral revascularization requires a reliable preoperative neurovascular baseline so postoperative perfusion can be assessed rapidly and accurately. Marking distal pulses (e.g., dorsalis pedis/posterior tibial) ensures consistent reassessment when pulses may be faint or difficult to locate due to chronic ischemia or postoperative edema/dressings. This directly supports early detection of acute graft occlusion or worsening ischemia, which is time-sensitive and limb-threatening. While coagulation studies and checklists are important, they do not provide the critical limb-specific baseline needed to compare postoperative circulation status.

Question 18

Which assessment parameters should the nurse consider to determine whether the snake is poisonous?

Accepted Answer

Answer reason: The key principle is that initial bedside differentiation between venomous and nonvenomous bites relies more on the bite pattern and evolving local/systemic findings than on the snake’s appearance. Venomous snakes often leave one or two distinct puncture wounds (fangs) and may produce rapidly progressive pain, swelling, ecchymosis, or systemic symptoms, making the wound pattern a useful assessment clue. Color and length are unreliable because many species have variable coloration and size, and the snake is often not seen clearly. The location of the marks does not determine venom; it is the pattern and associated tissue response that better supports suspicion of envenomation and need for close monitoring/antivenom evaluation.

Question 19

The parent of a 4-year-old child tells the pediatric nurse that the child's abdomen seems to be swollen. During further assessment, the parent tells the nurse that the child is eating well and that the activity level is unchanged. The nurse, suspecting the possibility of Wilms' tumor, would plan to avoid which during the physical assessment?

Accepted Answer

Answer reason: Deep or repeated abdominal palpation can increase intrarenal pressure and may cause the encapsulated renal mass to rupture, so it is avoided. Noninvasive assessments are appropriate because hematuria and hypertension can occur from renal involvement and renin secretion, and fever may indicate associated inflammation or infection. A common error is attempting to “confirm” a mass by palpation instead of using careful inspection and timely imaging orders per provider.

Question 20

SITUATION: The nurse is about to administer furosemide to a client who is complaining of palpitations. which action from the following options should be considered a priority by the nurse?

Accepted Answer

Answer reason: Palpitations can indicate an acute dysrhythmia that requires immediate assessment to determine stability and guide next actions. A 12-lead ECG quickly identifies rhythm/conduction abnormalities and ischemic patterns, and provides objective data before administering a medication that can worsen electrolyte-related arrhythmias. Furosemide can cause hypokalemia and hypomagnesemia, which increase dysrhythmia risk, so obtaining ECG data first is a safety-focused priority assessment. Notifying the provider may be appropriate after initial assessment data are obtained, while urine output measurement does not address the immediate potential cardiac risk.

Question 21

Which finding would alert a nurse that a hospitalized 6-year-old child is at risk for a severe asthma exacerbation?

Accepted Answer

Answer reason: Dependence on systemic steroids implies more severe, persistent airway inflammation and a higher likelihood of rapid deterioration and poor response to routine bronchodilator-only management. In contrast, an SpO2 of 95% and mild work of breathing are generally consistent with a milder presentation and do not, by themselves, signal impending severe decompensation. Absence of retractions is also not an alarm sign for severity in a stable child, whereas the historical severity marker warrants closer monitoring and escalation readiness.

Question 22

A client with chronic renal failure has completed a hemodialysis treatment. The nurse would use which of the following standard indicators to evaluate the client’s status after dialysis?

Accepted Answer

Answer reason: Hemodialysis primarily removes excess fluid and shifts electrolytes, so immediate post-treatment evaluation focuses on hemodynamic stability and net fluid removal. Comparing pre- and post-dialysis weight is the standard, direct measure of fluid volume removed. Vital signs (especially blood pressure and heart rate) detect common acute complications such as intradialytic hypotension, cramping, or volume depletion. BUN/creatinine and potassium can change with dialysis but are not the quickest, most practical bedside indicators of immediate post-dialysis status compared with weight and vital signs.

Question 23

A 20-year-old female attending college is found unconscious in her dorm room. She has a fever and a noticeable rash. She has just been admitted to the hospital. Which of the following tests is most likely to be performed first?

Accepted Answer

Answer reason: It can be performed within seconds and guides urgent treatment (e.g., dextrose) without delaying stabilization. Although fever with rash raises concern for serious infection (e.g., meningococcemia), cultures are typically obtained after initial life-threatening, readily correctable causes are ruled out and while resuscitation is underway. CT or ABGs may be appropriate based on airway/breathing status and neurologic exam, but they take longer and are not the fastest first-line screen for a reversible cause of unconsciousness.

Question 24

Nurse Mariane is caring for an infant with spina bifida. Which technique is most important in recognizing possible hydrocephalus?

Accepted Answer

Answer reason: In spina bifida (especially myelomeningocele), the risk of hydrocephalus is elevated due to associated hindbrain malformations and impaired CSF flow, so frequent, trend-based surveillance is critical. Serial occipital-frontal circumference measurements provide a rapid, noninvasive, bedside method to detect early abnormal growth trajectories. Imaging (e.g., MRI) can confirm diagnosis, but it is not the most important initial nursing technique for recognizing developing hydrocephalus. Lumbar puncture is not a screening method and can be unsafe when increased intracranial pressure is suspected.

Question 25

Seven-month-old Kenneth Baker is admitted to the hospital with a tentative diagnosis of Hirschsprung's disease. Which parental statement obtained during the nursing history most accurately describes the infant with this disorder?

Accepted Answer

Answer reason: " Hirschsprung's disease is a congenital absence of enteric ganglion cells leading to functional colonic obstruction and severe constipation with abdominal distention. A classic history is constipation with intermittent “overflow” or enterocolitis-type stools that can be described by parents as episodic diarrhea despite underlying obstruction. This option best reflects that paradoxical pattern compared with nonspecific findings like increased nursing or poor sleep. A flat abdomen is not typical; distention is more expected due to stool and gas retention proximal to the aganglionic segment.

Question 26

The nurse is caring for a client who had a permanent pacemaker inserted because of a complete heart block. The nurse determines that which client outcome indicates a successful procedure?

Accepted Answer

Answer reason: Seeing paced beats at a stable rate indicates the pacemaker is functioning and providing reliable rhythm support when native conduction is absent. Normal sinus rhythm is not expected to return simply because a pacemaker is placed; the device often paces the ventricles despite ongoing AV block. Normal vital signs or early ambulation may occur, but they are less specific than direct ECG evidence of effective pacing and capture.

Question 27

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome?

Accepted Answer

Answer reason: Tachypnea is typically the earliest and most sensitive bedside sign as the patient compensates to maintain oxygenation and blow off CO2. Crackles usually appear later as alveolar fluid increases, and wheezing is more characteristic of bronchospasm rather than diffuse alveolar damage. Intercostal retractions reflect significant respiratory distress and are generally a later, more severe manifestation than isolated tachypnea.

Question 28

The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64 beats per minute. Which action should the nurse take?

Accepted Answer

Answer reason: The described measurements indicate normal sinus rhythm: regular P waves with each QRS, PR interval within 0.12–0.20 seconds, narrow QRS (

Question 29

A client with Crohn’s disease is scheduled to receive an infusion of infliximab. What intervention by the nurse will determine the effectiveness of treatment?

Accepted Answer

Answer reason: A key expected outcome is decreased diarrhea, with bowel movements becoming less frequent and better formed, reflecting reduced mucosal inflammation. Laboratory monitoring such as leukocyte count or liver enzymes is more relevant to adverse effects and safety surveillance than to determining therapeutic response. Testing gastric fluid for occult blood is not a standard or targeted measure for Crohn’s disease activity after an infliximab infusion.

Question 30

During routine chest tube assessment, the nurse notes the presence of continuous bubbling in the water seal chamber of the closed chest drainage system. Which conclusion should the nurse draw from this data?

Accepted Answer

Answer reason: Continuous bubbling in the water-seal chamber indicates that air is entering the drainage system, which is abnormal except for brief bubbling with coughing/expiration early after insertion. This most commonly reflects an air leak from the patient (e.g., bronchopleural fistula) or from loose connections in the tubing or drainage unit. Suction level affects bubbling in the suction control chamber (wet system) rather than causing continuous bubbling in the water seal. A new pneumothorax would be suggested by worsening respiratory status and loss of expected tidaling, not by continuous water-seal bubbling alone.

Question 31

The nurse is assessing the client’s skin and wants to evaluate a site for petechiae. What technique can the nurse perform to complete this assessment?

Accepted Answer

Answer reason: Petechiae are pinpoint, nonblanching hemorrhagic lesions caused by capillary bleeding into the skin, so they do not fade with pressure. The key bedside technique is the blanch test: press with a finger or clear object to see whether the redness disappears. If the area fails to blanch, this supports petechiae/purpura rather than erythema from vasodilation or inflammation. Rubbing can traumatize the skin and is not diagnostic, and a tourniquet test is not a standard or necessary nursing assessment step and may be unsafe in some patients.

Question 32

A client is admitted with a pressure injury on the left hip. The nurse has entered the following goal on the standardized care plan, “skin heals by June 12.” Prior to this date, the nurse evaluates progress on reaching this goal. Which statement is the best notation of progress toward the goal?

Accepted Answer

Answer reason: Decreased erythema reflects reduced inflammation, and granulation tissue is a direct, observable sign of wound repair and progression toward closure. The other options primarily describe interventions (turning schedule, dressing change frequency) or only prevention of new breakdown, which do not best demonstrate that the existing pressure injury is healing. Outcome-focused, objective wound assessment findings best support progress toward the stated goal.

Question 33

A patient has undergone oral surgery after a motor vehicle accident. The nurse assessing the patient notices flushed and warm skin. Which of the following methods would be the most appropriate to measure the patient’s body temperature?

Accepted Answer

Answer reason: A noninvasive site that avoids the oral cavity is safest and most appropriate in this situation. The axillary route allows temperature assessment without interfering with the postoperative oral area and is commonly used when oral measurement is contraindicated. Rectal measurement is more invasive and typically avoided unless specifically indicated, and an arterial line is not a standard/appropriate method for routine temperature measurement.

Question 34

Nurse Allen is caring for a 35-year-old dark-skinned client with asthma who presents to the emergency department in acute respiratory distress. Given the client’s skin tone, Nurse Allen knows to assess for cyanosis in areas where it is most easily detected. Which area should she inspect to best identify signs of cyanosis?

Accepted Answer

Answer reason: Cyanosis reflects increased deoxygenated hemoglobin and is most reliably identified in well-vascularized tissues rather than pigmented skin. In dark-skinned clients, bluish or gray discoloration is easier to detect in oral mucosa (e.g., buccal mucosa, tongue, and inner lips) because melanin does not obscure the color change as much. This makes mucous membranes a higher-yield assessment site during acute respiratory distress when rapid recognition of hypoxemia matters. Nail beds and earlobes can show cyanosis, but visual detection is less dependable with darker skin tones and variable lighting.

Question 35

Nurse Collins is conducting a physical examination for Miss Taylor, a 19-year-old female client preparing for college. During the respiratory assessment, Nurse Collins observes the client’s respiratory excursion. What aspect of respiratory function is this observation primarily helping to assess?

Accepted Answer

Answer reason: Respiratory excursion is the visible and palpable rise and fall of the thoracic cage during breathing, reflecting symmetry and adequacy of chest wall expansion and ventilatory effort. Observing excursion helps detect abnormal patterns such as unequal expansion (e.g., atelectasis, pneumothorax, pleural effusion) or use of accessory muscles. Breath sounds require auscultation rather than simple observation, and vocal sounds are assessed with voice transmission tests (e.g., egophony/bronchophony). Lung vibrations (tactile fremitus) are evaluated by palpation, not by visually observing excursion.

Question 36

A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?

Accepted Answer

Answer reason: The key principle is to rapidly assess the cause and physiologic impact of marked polyuria after head trauma, where diabetes insipidus from ADH deficiency is a priority concern. Checking urine specific gravity is an immediate, noninvasive assessment that helps distinguish dilute urine consistent with DI (low specific gravity) from other etiologies and guides urgent fluid/electrolyte management. The findings of dry mucous membranes and dry skin indicate dehydration from free-water loss, making early confirmation of urine concentration clinically actionable. Anticipating renal failure is inconsistent with high urine output, and slowing IV fluids would worsen dehydration; skin emollients address comfort/skin integrity but do not treat the potentially life-threatening volume deficit.

Question 37

A nurse notes 2+ bilateral edema in the lower extremities of a client with myocardial infarction who was admitted two (2) days ago. The nurse would plan to do which of the following next?

Accepted Answer

Answer reason: New or worsening dependent edema after an MI suggests fluid volume excess and possible evolving cardiac pump failure, so the priority is to assess current fluid balance trends. Intake and output over the prior 48 hours provides immediate, objective data to corroborate fluid retention and guides whether escalation (e.g., diuretics, fluid/sodium limits) is needed. Changing diuretic timing to evening is unsafe because it increases nocturia and fall risk and does not address the cause. Sodium restriction and initiating daily weights may be appropriate later, but assessment data should be gathered first and diet/medication changes typically require a provider order.

Question 38

Nurse Chael is performing a skin assessment on a new resident in a long-term care facility. Which finding is of most concern?

Accepted Answer

Answer reason: Suspicious pigmented lesions should be treated as potentially malignant until proven otherwise, especially when they show ABCDE warning signs such as border irregularity and concerning color. A dark scalp lesion with an irregular border raises concern for melanoma, which can metastasize early and requires prompt dermatologic evaluation/biopsy. In contrast, thickened yellow toenails commonly reflect onychomycosis, and silvery scaling on extensor surfaces suggests psoriasis—both typically non-emergent chronic conditions. Striae are usually benign skin changes related to stretching or steroid exposure and are not immediately life-threatening compared with possible melanoma.

Question 39

A 24-year old man seeks medical attention for complaints of claudication in the arch of the foot. A nurse also notes superficial thrombophlebitis of the lower leg. The nurse would next assess the client for?

Accepted Answer

Answer reason: These findings in a young adult (distal foot claudication plus superficial thrombophlebitis) are classic for thromboangiitis obliterans (Buerger disease), a segmental inflammatory vasculitis strongly associated with tobacco use. Assessing for tobacco exposure directly targets the most important risk factor and the key modifiable cause that drives disease progression. Family history of peripheral vascular disease is less explanatory here because atherosclerotic PAD typically presents later in life and is less tied to migratory thrombophlebitis. Allergens and insect bites do not account for exertional ischemic pain and thrombophlebitis in this pattern.

Question 40

A client has been treated with antibiotic therapy for right lower-lobe pneumonia for 10 days and will be discharged today. Which of the following physical findings would lead the nurse to believe it is appropriate to discharge this client?

Accepted Answer

Answer reason: Discharge readiness after pneumonia treatment is supported by improving respiratory status and return toward normal assessment findings. Normal vesicular sounds over the lung bases indicate better aeration and reduced consolidation compared with expected crackles/bronchial sounds during active pneumonia. In contrast, persistent dyspnea and marked tachypnea indicate ongoing increased work of breathing and incomplete clinical recovery. Ongoing high fever suggests unresolved infection or complications and warrants further evaluation rather than discharge.

Question 41

A client diagnosed with anterior wall ST elevation myocardial Infarction is admitted to a cardiac stepdown unit. Which intervention should the nurse perform first?

Accepted Answer

Answer reason: Continuous ECG monitoring is the immediate priority in acute STEMI because lethal dysrhythmias (e.g., VT/VF, bradyarrhythmias, new conduction blocks) can occur suddenly and require rapid recognition and intervention. Establishing monitoring first creates real-time surveillance while other assessments are obtained and treatment is initiated, directly reducing risk of unrecognized deterioration. Vital signs and cardiopulmonary auscultation are important but are intermittent snapshots and do not provide continuous rhythm assessment. JVD assessment is less immediately time-critical and is more focused on volume status/right-sided failure rather than the most urgent STEMI complication risk.

Question 42

SITUATION: A nurse is caring for a client who has just returned to the unit after the implantation of an implantable cardioverter defibrillator (ICD). Which of the following is the priority nursing intervention to ensure safety and prevent infection?

Accepted Answer

Answer reason: New redness, warmth, swelling, tenderness, or drainage can indicate developing infection or hematoma that requires prompt intervention to prevent systemic spread or device-related complications. This action is the most direct intervention tied to “prevent infection” in the immediate post-implant period. Restricting arm movement supports lead stabilization, and avoiding electromagnetic sources is important teaching, but neither addresses early infection detection as the priority safety step right after return to the unit.

Question 43

When assessing the client with meningitis, the nurse looks for which manifestation as a frequent first sign of increased intracranial pressure?

Accepted Answer

Answer reason: In meningitis, cerebral edema and impaired CSF flow can reduce cerebral perfusion, making altered attention, restlessness, irritability, or confusion a frequent early assessment finding. Vital-sign changes of Cushing response (widened pulse pressure with rising systolic BP and irregular respirations) tend to be later signs of significantly rising ICP and impending herniation. A bounding pulse is nonspecific and does not reliably indicate early ICP elevation.

Question 44

Which assessment finding in a 35-year-old client with an intracranial hematoma should concern the nurse?

Accepted Answer

Answer reason: An abnormal plantar response (a pathologic Babinski pattern) reflects corticospinal tract dysfunction, which can occur with expanding hematoma and herniation risk. This is a high-priority neuro assessment change compared with musculoskeletal cramps or Parkinsonian rigidity. While meningeal signs can be serious, this finding most directly signals upper motor neuron involvement relevant to intracranial pathology progression.

Question 45

A 4-year-old child is receiving postoperative care for surgical resection of a Wilms tumor. In addition to urinary functioning, the nurse should make which priority postoperative assessment?

Accepted Answer

Answer reason: After nephrectomy for Wilms tumor, decreased bowel motility and postoperative ileus are common risks and can progress to abdominal distention, vomiting, and impaired respiratory effort if not recognized early. Assessing return of bowel sounds, passage of flatus/stool, abdominal distention, and tolerance of oral intake directly guides safe advancement of diet and need for interventions (e.g., ambulation, NG decompression). Neurologic status and activity level are general postop checks but are less specific to the major complication risk from this abdominal procedure, and bone pain is more relevant to metastatic evaluation than immediate postoperative surveillance.

Question 46

A 6-month-old infant being treated with chemotherapy for neuroblastoma feeds poorly and vomits frequently. The nurse would use which assessment to best determine the infant’s fluid status?

Accepted Answer

Answer reason: With poor intake and frequent vomiting, small absolute volume losses can quickly produce clinically important dehydration, and daily weights capture this early and objectively. Urine output can lag behind and is influenced by renal perfusion and stress responses, while urine specific gravity is affected by renal concentrating ability and is less reliable in some illness states. Hemoglobin/hematocrit may suggest hemoconcentration but are nonspecific and can be confounded by chemotherapy-related cytopenias and other factors.

Question 47

A child with a brain tumor has shown symptoms of diabetes insipidus. What should the nurse monitor to provide ongoing assessment of this condition?

Accepted Answer

Answer reason: Ongoing nursing assessment focuses on tracking urine concentration and fluid balance; urine specific gravity provides a rapid bedside indicator of how dilute the urine is and whether therapy is effective. Blood glucose monitoring targets diabetes mellitus rather than DI. ACTH and amylase are not primary markers of posterior pituitary-related water balance disturbances.

Question 48

A client with a bowel resection and anastomosis returns to his room with an NG tube attached to observations indicates that the nasogastric suction is working properly?

Accepted Answer

Answer reason: Gastric decompression via NG suction is intended to prevent gastric distention and reduce postoperative nausea/vomiting by removing air and gastric contents. A soft, non-distended abdomen is the most direct bedside finding suggesting the stomach and proximal bowel are not becoming distended, consistent with effective suction. The ability to swallow and the condition of the abdominal dressing do not reflect NG tube function. Active bowel sounds relate more to return of peristalsis rather than whether the suction apparatus is effectively decompressing gastric contents.

Question 49

A high ammonia level contributes to hepatic encephalopathy. Which nursing implementation needs to be added to the nursing care plan as this level continues to increase?

Accepted Answer

Answer reason: More frequent neuro assessments help identify changes in level of consciousness, orientation, asterixis, and progression toward coma so interventions can be escalated promptly. This action is the most direct, sensitive monitoring strategy tied to the pathophysiology of hyperammonemia. Oxygen saturation monitoring and intake/output may be appropriate based on overall condition, but they do not target the primary, expected complication of increasing ammonia. Mouth care supports comfort and hygiene but does not address the key safety risk of neurologic decline.

Question 50

A nurse is caring for a client who is newly admitted to the facility for chest pain. At which of the following times should the nurse begin teaching about drugs and discharge planning?

Accepted Answer

Answer reason: Early teaching lets the nurse tailor medication and lifestyle instructions as the diagnostic workup evolves and reinforces information over multiple encounters. Waiting until a definitive diagnosis or the day of discharge risks rushed teaching, poor comprehension, and missed opportunities to identify learning needs and follow-up resources. Family involvement can be helpful, but it should not delay initiation of teaching; it can be incorporated later as part of an ongoing education plan.

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