Question 1

The nurse would question which of the following methods of pain relief during repair of an episiotomy?

Accepted Answer

Answer reason: A paracervical block primarily provides cervical/uterine pain relief (e.g., for first-stage labor procedures) and does not reliably anesthetize the perineum for suturing. Using it for episiotomy repair risks inadequate pain control and unnecessary exposure to procedure-specific risks. In contrast, pudendal block and local infiltration directly target the perineal tissues involved in the repair, and an epidural can provide sufficient perineal anesthesia if still effective.

Question 2

The nurse is caring for a client who is having a liver biopsy. Which positioning should the nurse place the client in immediately following the procedure?

Accepted Answer

Answer reason: After a percutaneous liver biopsy, the priority is minimizing hemorrhage from the puncture site. Positioning the client on the right side places firm pressure over the biopsy tract in the liver capsule, promoting hemostasis and reducing the risk of bleeding. This position is typically maintained for the immediate post-procedure period while vital signs and pain are closely monitored for signs of internal bleeding. Supine or left lateral positioning does not provide the same direct pressure to the liver biopsy site, and dangling increases orthostatic risk without bleeding control benefit.

Question 3

The nurse knows that if a client requires oxygen delivery at a FIO2 of 92%, the appropriate system would be a?

Accepted Answer

Answer reason: High FiO2 requirements are met with high-flow or reservoir systems capable of delivering very high oxygen concentrations. A nonrebreather-type setup (mask with reservoir bag) can deliver roughly 60% to near 100% FiO2 when supplied with adequate flow and a well-fitting mask, matching a target around 92%. A Venturi mask is designed for precise, controlled oxygen delivery but typically tops out well below this level (commonly up to about 50%). Nasal cannula and face tent provide variable, lower FiO2 and are inappropriate when near-maximal oxygen concentration is required.

Question 4

Which intervention may be a possible treatment choice for talipes equinovarus?

Accepted Answer

Answer reason: Progressive manipulation followed by repeated casting (Ponseti-style serial casts) is a standard first-line, noninvasive therapeutic approach to realign the foot over time. Traction is not a typical treatment for this congenital foot deformity, and braces are more commonly used for maintenance after initial correction rather than as the primary corrective method. Range-of-motion exercises alone are insufficient to correct the structural malalignment and can delay effective treatment if used as the main intervention.

Question 5

Which nursing intervention would be correct for a woman having intracavitary radiation for cancer of the cervix?

Accepted Answer

Answer reason: Strict bed rest (often with limited movement and log-rolling if permitted) is a key nursing intervention while the implant is in place. A high-residue diet is inappropriate because pelvic radiation increases risk of diarrhea and rectal irritation, so low-residue is typically used. Fowler’s positioning and intermittent catheterization may be ordered in specific situations, but they are not the primary universal intervention emphasized for intracavitary cervical radiation compared with immobilization.

Question 6

A client is complaining of severe flank and abdominal pain. A flat plate of the abdomen shows urolithiasis. Which intervention is important?

Accepted Answer

Answer reason: Urolithiasis management includes monitoring for stone passage and preventing obstruction-related complications. Straining the urine allows retrieval of the calculus for analysis, which guides targeted prevention (e.g., dietary changes, medications) and helps confirm that the stone has passed. Limiting fluids can worsen urinary stasis and increase risk of ongoing stone formation, while strict bed rest is not a key therapeutic measure and ambulation may aid passage. A high-calcium diet is not a universal recommendation and may be inappropriate depending on stone type; the priority intervention is capturing the stone.

Question 7

A child has developed difficulty ambulating and tends to walk on his toes. Which surgical technique may benefit the client?

Accepted Answer

Answer reason: Lengthening or releasing the Achilles tendon directly addresses this limitation, improving heel strike and overall ambulation mechanics. In contrast, adductor or hamstring releases primarily target hip adduction or knee flexion contractures rather than ankle plantarflexion deformity. Plantar fascia release is aimed at cavus/plantar fascia tightness and is not the usual corrective procedure for toe-walking driven by equinus.

Question 8

The nurse admits a client to the hospital for a carotid endarterectomy. The nurse should expect to find which condition documented in the client’s history?

Accepted Answer

Answer reason: Carotid endarterectomy is performed to remove obstructive plaque from the carotid artery to reduce the risk of ischemic stroke. The underlying pathology leading to carotid stenosis is typically atherosclerotic disease with intimal plaque buildup and potential embolization. A history of systemic vascular disease (e.g., coronary or peripheral artery disease) commonly coexists and supports this indication. The other options are not primary etiologies for carotid plaque requiring surgical removal, even though comorbid organ disease may affect perioperative risk and monitoring.

Question 9

A transjugular intrahepatic portosystemic shunt (TIPS) is performed for which condition?

Accepted Answer

Answer reason: TIPS is a therapeutic procedure designed to decompress the portal venous system by creating a channel between the portal vein and a hepatic vein, thereby lowering portal pressure. This directly treats portal hypertension and its complications such as refractory ascites and variceal bleeding risk. While active/ruptured esophageal varices may prompt urgent measures, the underlying indication for placing TIPS is reduction of portal pressure rather than treating the rupture itself. Jaundice reflects impaired bilirubin handling, and jugular venous distension reflects right-sided heart issues; neither is addressed by an intrahepatic portosystemic shunt.

Question 10

The nurse is caring for a client with urine retention. The physician has ordered the client to be catheterized. Which of the following catheters would be the most appropriate for the nurse to select to perform the procedure?

Accepted Answer

Answer reason: A straight (intermittent) catheter is designed for single insertion and removal, making it appropriate when the order is simply to catheterize for retention without an ongoing need for continuous drainage. An indwelling urinary catheter is used when continuous bladder drainage is required (e.g., strict output monitoring or prolonged retention), which increases CAUTI risk if not clearly indicated. A Coudé catheter is reserved for difficult male catheterization (e.g., prostatic enlargement/urethral obstruction), and a three-way catheter is primarily for continuous bladder irrigation (e.g., post-TURP hematuria), neither of which is implied here.

Question 11

The nurse is caring for the older adult client with normal pressure hydrocephalus (NPH). Which treatment measure should the nurse anticipate?

Accepted Answer

Answer reason: A shunt procedure provides ongoing drainage from the ventricles to another body cavity, addressing the underlying CSF circulation problem. A lumbar drain may be used temporarily as a diagnostic or short-term therapeutic trial but is not the standard long-term treatment. Carotid endarterectomy treats carotid stenosis, and anticonvulsants do not correct CSF accumulation and are only indicated if seizures are present.

Question 12

Which is the most important instrument used as a diagnostic and monitoring tool for determining the severity of a shock state?

Accepted Answer

Answer reason: A pulmonary artery catheter provides pulmonary artery pressures, pulmonary capillary wedge pressure, cardiac output, and mixed venous oxygen saturation, allowing differentiation of shock types and quantification of severity. An arterial line offers continuous blood pressure monitoring but does not quantify cardiac output or filling pressures to define the underlying hemodynamic profile. Urine output and ECG monitoring are important adjuncts for perfusion and dysrhythmia detection, but they are indirect markers and less definitive for grading and characterizing shock.

Question 13

Which statement best explains an open reduction of a fractured femur?

Accepted Answer

Answer reason: Open reduction involves surgically exposing the fracture to realign the bone, and it is typically paired with internal fixation to stabilize the fragments. Internal fixation devices (plates, screws, intramedullary nails, wires) maintain alignment and allow controlled healing while reducing malunion and prolonged immobilization risks. Traction and casting are more characteristic of nonoperative management or temporary stabilization rather than the defining feature of open reduction. Crutch use may occur postoperatively but does not explain what open reduction entails.

Question 14

Client teaching for a client with Gardner-Wells tongs should include which reason for their use?

Accepted Answer

Answer reason: By restoring alignment and maintaining immobilization, traction helps decrease muscle spasm and mechanical instability, which in turn reduces pain and risk of further spinal cord compromise. They are not used to lower intracranial pressure; that is managed with measures aimed at cerebral perfusion and edema control. Traction does not directly prevent DVT (that requires mobility/anticoagulation/mechanical prophylaxis) and it does not guarantee avoidance of surgery because some unstable injuries still require operative fixation.

Question 15

The nurse is preparing a client to have a chest tube inserted in the right upper chest. What is the priority role of the nurse?

Accepted Answer

Answer reason: Having the drainage system assembled, functional, and ready to connect immediately prevents air entry into the pleural space and supports prompt restoration of negative intrathoracic pressure. This also reduces delays once the provider places the tube, lowering risk of deterioration (e.g., worsening pneumothorax) and maintaining a closed system. Insertion itself is a provider task, while obtaining imaging is important but not the immediate priority compared with ensuring the drainage setup is ready at the bedside.

Question 16

The client has developed a pleural effusion. The nurse anticipates that the most appropriate intervention would be?

Accepted Answer

Answer reason: This procedure directly evacuates pleural fluid and can rapidly relieve dyspnea while also helping identify the underlying cause (e.g., transudate vs exudate). A chest tube is typically reserved for ongoing drainage needs such as large, recurrent, complicated effusions/empyema or pneumothorax rather than the first anticipated step in an uncomplicated effusion. Paracentesis targets ascitic fluid in the abdomen, and waiting for spontaneous drainage is unsafe because worsening respiratory compromise can occur.

Question 17

The nurse is preparing a client for a colonoscopy the following morning. The nurse should expect to administer which medication to the client?

Accepted Answer

Answer reason: Colonoscopy requires a clean colon so the provider can visualize the mucosa and reduce the risk of missed lesions and procedure-related complications. An isotonic PEG-electrolyte bowel prep induces rapid catharsis while helping limit significant fluid and electrolyte shifts compared with hyperosmotic laxatives. Anticoagulants like warfarin are typically held before invasive procedures due to bleeding risk rather than administered as preparation. Vitamin K would reverse anticoagulation and is not a routine colonoscopy prep medication, and calcium carbonate is unrelated to bowel cleansing.

Question 18

The nurse changes a wet-to-dry dressing for a client who has a pressure ulcer with infected, necrotic tissue. The nurse knows the purpose of the wet-to-dry dressing is to?

Accepted Answer

Answer reason: Wet-to-dry dressings provide a form of mechanical debridement by allowing dried gauze to adhere to devitalized tissue and exudate, which are removed when the dressing is pulled off. This is particularly relevant when necrotic tissue is present, because removing nonviable material decreases bacterial burden and supports granulation. This method does not primarily aim to keep the wound moist; in fact, modern moist wound healing often uses other dressings and wet-to-dry can desiccate viable tissue. It also commonly increases discomfort during removal, so pain reduction is not its purpose, and infection prevention is an indirect benefit rather than the main goal.

Question 19

The nurse performs tracheal suctioning through a client’s nose. Which is the correct method for suctioning the client?

Accepted Answer

Answer reason: Nasotracheal suctioning should minimize mucosal trauma and hypoxemia by using proper technique and limiting airway irritation. Lubrication reduces friction against the nasal mucosa, decreasing bleeding and discomfort during insertion. Suction is applied only while withdrawing the catheter (with gentle rotation) to avoid mucosal damage and excessive removal of oxygen. Suctioning should be brief (typically 10–15 seconds per pass), so a prolonged duration like 45 seconds markedly increases the risk of hypoxia and dysrhythmias.

Question 20

The nurse is reviewing orders for the 10-year-old about to undergo a cardiac catheterization in two hours. Which prescription should the nurse question with the HCP?

Accepted Answer

Answer reason: Allowing oral intake (even clear liquids) close to a procedure scheduled in 2 hours conflicts with standard fasting guidelines and increases aspiration risk. A CBC may be appropriate to evaluate baseline hemoglobin/hematocrit and platelets when vascular access and potential bleeding are concerns. Height/weight and establishing IV access with a saline lock are routine pre-procedure steps to support accurate dosing and timely medication/contrast administration.

Question 21

A client with colon cancer is scheduled to receive radiation therapy prior to surgery. What should the nurse include in her teaching about the use of radiation therapy?

Accepted Answer

Answer reason: Preoperative (neoadjuvant) radiation is used to shrink a tumor and decrease local disease burden to make surgical resection more feasible and improve local control. Teaching should emphasize that the goal is often tumor downstaging rather than guaranteeing eradication of all cancer cells. Radiation can kill malignant cells, but “eliminates” implies complete destruction and is not a reliable, general outcome to promise. It also does not promote postoperative bowel healing; in fact, radiation can impair tissue healing due to inflammation and fibrosis.

Question 22

After a liver biopsy, a nurse should place a client in which position?

Accepted Answer

Answer reason: Positioning the client on the right side places the biopsy site dependent and compresses the liver against the abdominal wall, helping tamponade bleeding and reduce risk of bile leak. Keeping the bed flat further supports hemostasis by minimizing strain and movement at the site. Left side-lying positioning fails to provide direct pressure over the biopsy tract and is therefore less protective against bleeding complications.

Question 23

A client has been treated with I.V. antibiotics for osteomyelitis. The treatment has not been effective. Which intervention would be the most appropriate for this client?

Accepted Answer

Answer reason: Removing devitalized tissue reduces bacterial load, improves local perfusion, and allows systemic antibiotics to be effective against remaining viable infected bone. This is a standard escalation step in chronic or refractory osteomyelitis management before considering limb-loss procedures. Amputation is reserved for uncontrolled infection, extensive destruction, or life-threatening complications when limb salvage measures fail.

Question 24

The parent of an infant diagnosed with clubfoot is discussing the casting treatment regimen with the nurse. The nurse determines further instruction is not needed when the parent states that the cast will be changed?

Accepted Answer

Answer reason: Serial casting for infant clubfoot (e.g., Ponseti method) requires frequent cast changes to gradually correct foot alignment and accommodate rapid growth. A change interval around 1–2 weeks is expected, and longer intervals raise risk of poor correction and skin/pressure complications. Waiting until developmental milestones (crawling or walking) is unsafe because correction should be completed early to optimize function and prevent worsening deformity. An 8-week interval is far too long for appropriate repositioning and reassessment of circulation, skin integrity, and fit.

Question 25

Children with chronic otitis media commonly require surgery for a myringotomy and ear tube placement. Which management strategy explains the purpose of the ear tubes?

Accepted Answer

Answer reason: By keeping the middle ear aerated, they reduce negative pressure, decrease fluid accumulation, and lower the risk of conductive hearing loss and recurrent infections. They are not intended as a route to deliver antibiotics or to “flush” the middle ear. Increasing pressure would worsen discomfort and effusion rather than resolve it.

Question 26

A client status post-cholecystectomy has a T-tube placed during the surgery. Which action should the nurse take when caring for the T-tube?

Accepted Answer

Answer reason: A T-tube is a biliary drain intended to allow passive drainage of bile and to decompress the common bile duct after surgery. Standard nursing care is to maintain dependent drainage into a collection device so output can be measured and the tract is not forced open or contaminated. Routine aspiration or suction is not used because negative pressure can injure biliary mucosa and disrupt healing. Irrigation is only performed with a specific provider order due to the risk of forcing bile/contaminants into the duct and causing obstruction or infection.

Question 27

When changing a dressing on a pressure ulcer, a nurse notes necrotic wound tissue. Based on this assessment finding, the nurse anticipates that the physician will order which procedure?

Accepted Answer

Answer reason: The appropriate therapeutic procedure is removal of devitalized tissue so the wound bed is clean and able to heal and so infection risk is reduced. Incision and drainage is aimed at evacuating an abscess/collection, not routine management of necrosis in a pressure injury. Wound culture may be needed if infection is suspected, but it does not address the primary barrier to healing identified here. Antiseptic irrigation can be cytotoxic to healthy tissue and is not the key intervention for necrotic slough/eschar.

Question 28

The nurse is planning care for the child with CF. What assessment finding and associated intervention should the nurse anticipate?

Accepted Answer

Answer reason: Airway clearance techniques (eg, chest physiotherapy with percussion/postural drainage) are a key therapeutic procedure to mobilize secretions and improve ventilation. This pairing directly matches a common assessment finding in CF (retained mucus) with a standard, evidence-based intervention. A common distractor is focusing on stool changes or generic fluids, but the stem emphasizes planning care anticipating respiratory management needs.

Question 29

A nurse assists a physician during paracentesis. When documenting the procedure, which information should the nurse include?

Accepted Answer

Answer reason: Recording the provider’s name clarifies accountability, while the patient’s response captures immediate assessment data such as pain, vital sign stability, complications, and overall tolerance. This information directly reflects the nursing responsibility to document objective findings and patient status after a therapeutic procedure. By contrast, the rationale for the procedure is typically found in the provider’s order/medical record and is not the key nursing documentation focus during the procedure note.

Question 30

The nurse is auscultating the lungs of a client following chest tube insertion. What assessment finding would indicate to the nurse correct chest tube placement?

Accepted Answer

Answer reason: Vesicular sounds are the expected normal finding over most of the lungs, including the upper fields, when ventilation is adequately restored after pleural drainage. Bronchial sounds at the bases or bronchovesicular sounds across both lung fields suggest abnormal transmission or consolidation rather than normal re-expansion patterns. Crackles on the affected side can occur with atelectasis, fluid, or incomplete re-expansion and therefore does not best indicate correct placement/function.

Question 31

A 4-year-old child had a subungual hemorrhage of the toe after a jar fell on his foot. Electrocautery is performed. The nurse explains to the parents that electrocautery is done to?

Accepted Answer

Answer reason: Subungual hemorrhage (hematoma) creates painful pressure beneath the nail from trapped blood after a crush injury. Electrocautery is used to trephinate the nail, allowing drainage and rapid decompression, which directly decreases pain. Creating a controlled drainage pathway also lowers the chance that pooled blood becomes a medium for bacterial growth compared with leaving it sealed under the nail. It is not performed to preserve nail growth or prevent discoloration; nail appearance and growth depend mainly on the extent of nail-bed/matrix injury.

Question 32

The nurse determines that an adolescent client with scoliosis understands the treatment plan when the client makes which statement?

Accepted Answer

Answer reason: ” Bracing for adolescent idiopathic scoliosis is a long-term therapeutic procedure aimed at preventing curve progression during periods of skeletal growth, so adherence over an extended timeframe is expected. Wearing the brace only after school reflects misunderstanding because effective bracing typically requires many hours per day to be beneficial. Avoiding exercises that stretch or strengthen the back is incorrect; activity is generally encouraged unless specifically restricted. Routine removal at night is not universally appropriate because prescribed wear schedules often include nighttime, depending on the brace type and provider orders.

Question 33

Which nursing intervention is appropriate when suctioning a tracheostomy tube?

Accepted Answer

Answer reason: Safe tracheostomy suctioning aims to clear secretions while minimizing hypoxemia and airway trauma. Advancing only a short distance beyond the end of the tracheostomy tube helps avoid contact with the carina and bronchial mucosa, reducing bleeding, bronchospasm, and vagal-induced bradycardia. The child should be hyperoxygenated (not hypoventilated) before and between passes to prevent desaturation. Routine instillation of normal saline is not recommended because it can drive bacteria deeper, increase coughing/bronchospasm, and worsen oxygenation.

Question 34

The nurse is planning care for a client with a late-stage burn wound to promote healing. What is the most important intervention for the nurse to include?

Accepted Answer

Answer reason: Debridement reduces bioburden and allows topical agents and dressings to contact viable tissue, improving oxygenation and promoting closure. Compression wraps and sun protection are important longer-term measures (scar management and pigment/UV protection) but do not address the primary barrier to wound healing in a late-stage burn. Irrigation can help cleanse the wound, but without removing eschar, ongoing healing remains impaired and infection risk persists.

Question 35

The nurse begins to hear high-pressure alarms in the room of the client requiring respiratory assistance with a ventilator. Which is the best action by the nurse?

Accepted Answer

Answer reason: High-pressure ventilator alarms indicate increased resistance to airflow, which can rapidly compromise ventilation if not corrected. The safest first nursing action is to quickly assess for common correctable mechanical causes such as kinked/occluded tubing, water in the circuit, or disconnections/malposition that increase airway pressure. This step is immediate, within nursing scope, and can resolve the issue without altering prescribed settings or delaying care. Silencing/restarting the ventilator treats the noise rather than the cause and risks missing a critical obstruction, while changing tidal volume is a provider-directed ventilator adjustment unless specifically ordered per protocol.

Question 36

The nurse is assisting the health care provider with the application of a cast. Which of the following nursing interventions would be included in the immediate cast care?

Accepted Answer

Answer reason: Fresh plaster casts are soft and vulnerable to deformation until fully set, so handling must prevent creating pressure points that can indent the cast. Using the palms distributes pressure evenly and reduces the risk of localized compression that can lead to skin breakdown, impaired circulation, or nerve injury. Resting a wet cast on a hard surface can flatten it and compromise limb alignment and comfort. Plaster residue should not be poured into sinks because it can harden and clog plumbing, but that is a disposal issue rather than the key immediate patient-safety measure during application.

Question 37

A nurse is caring for a 2-year-old child who weighs 25 lb (11.3 kg) and has a simple fracture of his femur. For this client, which initial treatment is most likely?

Accepted Answer

Answer reason: Bryant’s traction is specifically used for toddlers/small children (typically under about 3 years and under ~30 lb) with femoral shaft fractures, using skin traction with the hips flexed and legs elevated. This matches the client’s age (2 years) and weight (25 lb). Skeletal traction and surgical pinning are more invasive and are more typical for older/heavier children or specific complicated fracture patterns, while immediate casting is not the most likely first step in this size/age group when traction is standard initial management.

Question 38

The physician orders a continuous positive airway pressure (CPAP) mask for a client. The nurse explains to the client that CPAP provides?

Accepted Answer

Answer reason: CPAP works by maintaining continuous positive pressure throughout the respiratory cycle, which functions like PEEP to prevent alveolar collapse and improve functional residual capacity. The key benefit is improved oxygenation via alveolar recruitment, especially by keeping alveoli open at end-expiration when they are most likely to collapse. Simply delivering “extra oxygen” or a “constant flow of oxygen” describes oxygen therapy flow characteristics, not the pressure-based mechanism of CPAP. A vague statement about breathing more easily is incomplete because it does not capture the essential end-expiratory pressure effect that improves gas exchange.

Question 39

A client is undergoing a thoracentesis at the bedside. The nurse assists the client to an upright position with a table and pillow in front of him to support his arms. Which rationale for this intervention is correct?

Accepted Answer

Answer reason: Upright positioning with arms supported maximizes chest expansion and helps pleural fluid layer dependently at the lung bases, which makes the effusion easier to locate and drain. Flexing forward stabilizes the client and widens the intercostal spaces to facilitate needle insertion into the pleural space. While careful technique reduces risk of lung puncture, the primary nursing rationale for this positioning is to optimize access to the pleural fluid collection. Comfort may improve with support, but it is secondary to procedural access and safety.

Question 40

The nurse is performing percussion and postural drainage on the left lower lobe of a client diagnosed with pneumonia. The nurse is aware that the client should be placed in which position?

Accepted Answer

Answer reason: For the lower lobes, the involved bronchial segments drain best with the client in a head-down (Trendelenburg-type) position, which is achieved by elevating the foot of the bed. A supine head-down position targets posterior/basal lower-lobe segments more appropriately than head-elevated positions, which would work against gravity for lower-lobe drainage. Side-lying on the affected side is generally not used to drain that side’s lower-lobe segments and can worsen ventilation-perfusion matching in some pneumonia patients.

Question 41

The nurse and client are updating the client’s asthma action plan. Which information should be updated on the action plan?

Accepted Answer

Answer reason: A peak flow

Question 42

The nurse is caring for the client with a left-sided chest tube attached to a wet suction chest tube system. Which observation by the nurse would require immediate intervention?

Accepted Answer

Answer reason: Chest tube drainage must flow freely by gravity to prevent backflow and loss of effective pleural drainage. A dependent loop creates a fluid-filled trap that can increase resistance, promote backflow into the pleural space, and impair lung re-expansion, which can quickly worsen respiratory status. It also increases the risk of tubing kinks or accidental traction/dislodgement if it hangs off the bed. By contrast, gentle bubbling in a wet suction chamber is expected when suction is functioning, and an occlusive dressing is standard to maintain an airtight seal.

Question 43

A 23-year-old client develops cardiac tamponade when the car he was driving hits a telephone pole; he wasn’t wearing a seat belt. The nurse helps the physician perform a pericardiocentesis. Which outcome would indicate that the treatment has been effective?

Accepted Answer

Answer reason: Pericardiocentesis removes the fluid, restoring preload and improving cardiac output, which should raise the blood pressure. Clinical signs of tamponade such as jugular venous distention, muffled heart sounds, and pulsus paradoxus are expected to lessen rather than persist after effective drainage. Persistent neck vein distention or pulsus paradoxus would suggest ongoing impaired filling or inadequate decompression.

Question 44

Which of the following instructions should the nurse include in the preoperative teaching for a client scheduled for closed spine surgery?

Accepted Answer

Answer reason: Closed (minimally invasive) spine surgery is performed through small incisions using specialized instruments and visualization, commonly via an endoscope. Preoperative teaching should set accurate expectations about the technique to reduce anxiety and support informed participation in care. Minimally invasive approaches generally aim to reduce tissue disruption, pain, blood loss, and length of recovery rather than increase them. Statements implying higher risk or markedly longer recovery are not generally true compared with open procedures, and “intense” physical therapy is not a universal requirement for all patients.

Question 45

The nurse is caring for a client who has been placed in traction prior to surgery. The client asks the nurse what is the purpose of the traction. What is the best response by the nurse?

Accepted Answer

Answer reason: Traction is a therapeutic procedure used to maintain alignment, reduce and stabilize fractures/dislocations, and decrease painful muscle spasm by applying a controlled pulling force. This reduces further soft-tissue injury and helps prevent additional trauma while awaiting definitive surgical repair. Increasing activity or assisting with routine repositioning is not the primary goal and can actually disrupt alignment if done improperly. Skin breakdown prevention is a nursing care priority during traction, but it is not the purpose of traction itself.

Question 46

A preoperative client is scheduled for surgical resection after being diagnosed with lung cancer. The client correctly states that the procedure will?

Accepted Answer

Answer reason: Surgical cancer resection aims for complete excision with “clear margins” to reduce local recurrence. Taking a rim of surrounding tissue increases the likelihood that microscopic malignant cells beyond the visible tumor are also removed. Options describing minimal surrounding tissue or partial tumor removal reflect debulking or inadequate margins and do not match the intent of curative resection when feasible. References to removing “collapsed alveoli” are not a standard surgical goal and confuse pathophysiology with oncologic operative principles.

Question 47

A comatose client requires a nasopharyngeal airway for suctioning. After the airway is inserted, he gags and coughs. The priority intervention by the nurse would be?

Accepted Answer

Answer reason: Gagging and coughing after insertion indicates the airway is likely too long and is stimulating the posterior pharynx, increasing risk of vomiting and aspiration. The immediate priority is to correct airway sizing to maintain patency while minimizing airway reflex stimulation. A shorter nasopharyngeal airway is selected to sit above the epiglottis and reduce irritation while still facilitating suctioning. Simply repositioning may not resolve excessive length, and leaving it in place is unsafe due to ongoing airway stimulation and aspiration risk. Removing it and suctioning without an adjunct can increase mucosal trauma and may be less effective if the tongue or soft tissues obstruct the airway.

Question 48

A nurse is assessing an 18-month-old infant who’s in Bryant’s traction for a fractured left femur. The infant is properly positioned when?

Accepted Answer

Answer reason: Bryant’s traction is used in young children with femur fractures to maintain alignment by suspending both lower extremities with hips flexed. Proper positioning requires both legs to be elevated so the buttocks are just off the bed, creating effective countertraction from the child’s body weight. Suspending only the injured leg would create pelvic tilt and poor alignment, increasing risk of malreduction and neurovascular compromise. Extending the legs flat with the body eliminates the intended traction vector and reduces fracture stabilization.

Question 49

A nurse is discharging a 10-month-old client with a prescription for eardrops. The nurse instructs the parents on the correct administration of the eardrops. It is most important to teach the parents to do which of the following?

Accepted Answer

Answer reason: Proper otic drop administration depends on straightening the external ear canal to ensure the medication reaches the intended area and to reduce the risk of ineffective treatment. In infants and toddlers under age 3, the ear canal is best straightened by pulling the pinna/earlobe down and back. Pulling the ear up and back is the technique for older children and adults and can misdirect drops in a 10-month-old. This instruction is a key safety/therapeutic procedure teaching point at discharge to maximize effectiveness and minimize persistent infection or discomfort.

Question 50

The male client is scheduled for gamma knife stereotactic surgery for a brain tumor. Which preoperative instruction should the nurse discuss with the client?

Accepted Answer

Answer reason: Gamma knife is a noninvasive stereotactic radiosurgery procedure that delivers focused radiation without an incision, so typical postoperative restrictions related to wound care and surgical recovery are minimal. Teaching should emphasize that most clients can resume usual activities relatively quickly, with only short-term guidance such as monitoring for headache, nausea, or other neurologic changes. Instructions about head-of-bed elevation are more associated with managing increased intracranial pressure or post-craniotomy care rather than this outpatient-type procedure. Advising sunscreen/avoiding bright lights and taking two weeks off work are not standard preoperative expectations for gamma knife treatment.

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