Question 1

The client has elected to receive epidural anesthesia to relieve labor pain. If the client experiences hypotension, the nurse would?

Accepted Answer

Answer reason: Epidural anesthesia can cause sympathetic blockade, leading to vasodilation and hypotension. The priority nursing action is to increase IV fluids to restore preload and blood pressure. Trendelenburg is not recommended in pregnancy. Decreasing fluids worsens hypotension, and oxygen is supportive but does not correct the primary cause.

Question 2

A week after kidney transplantation, a client develops a temperature of 101°F (38.3°C), the blood pressure is elevated, and there is tenderness over the transplanted kidney. The serum creatinine is rising and urine output is decreased. The x-ray indicates that the transplanted kidney is enlarged. Based on these assessment findings, the nurse anticipates which treatment?

Accepted Answer

Answer reason: Findings a week post-transplant—fever, graft tenderness, rising creatinine, decreased urine output, and enlarged kidney—indicate acute rejection. Management is to increase immunosuppression (e.g., high-dose steroids/antirejection agents), not antibiotics, dialysis, or graft removal.

Question 3

Shortly after starting an IV antibiotic, a client develops wheezing, facial swelling, and hypotension. Which action should the nurse take FIRST?

Accepted Answer

Answer reason: These findings indicate an acute anaphylactic reaction. The priority is to stop the offending agent and administer epinephrine to reverse airway edema and cardiovascular collapse. Positioning and notification occur after life-saving treatment.

Question 4

A client receiving IV morphine for postoperative pain becomes difficult to arouse and has a respiratory rate of 8/min. Oxygen saturation is decreasing. Which intervention is MOST appropriate?

Accepted Answer

Answer reason: The client shows signs of opioid-induced respiratory depression, an unexpected adverse response. Naloxone rapidly reverses opioid effects and is the priority intervention. Oxygen and positioning are supportive but do not correct the cause.

Question 5

During a blood transfusion, a client reports back pain and chills, and the nurse notes dark urine in the catheter bag. Vital signs show tachycardia and hypotension. Which action should the nurse take FIRST?

Accepted Answer

Answer reason: These findings suggest an acute hemolytic transfusion reaction. The immediate priority is to stop the transfusion to prevent further hemolysis while maintaining IV access with normal saline for supportive care.

Question 6

A client receiving vesicant chemotherapy through a peripheral IV reports burning pain at the site, and the nurse observes swelling and blanching. Which action should the nurse take FIRST?

Accepted Answer

Answer reason: These findings indicate possible chemotherapy extravasation. The priority is to stop the infusion while leaving the catheter in place to allow administration of antidotes if indicated. Flushing or removing the catheter can worsen tissue injury.

Question 7

A client started on an ACE inhibitor develops sudden lip and tongue swelling without rash or itching. Breath sounds are clear but voice is muffled. Which intervention is MOST appropriate?

Accepted Answer

Answer reason: ACE inhibitor–associated angioedema can rapidly compromise the airway and may not respond to antihistamines. Immediate airway vigilance and provider notification are critical to prevent obstruction.

Question 8

A client with diabetes receives the usual dose of rapid-acting insulin but eats very little due to nausea. Thirty minutes later, the client becomes diaphoretic and confused. What should the nurse do FIRST?

Accepted Answer

Answer reason: The client shows classic signs of hypoglycemia following insulin administration without adequate intake. Immediate glucose assessment and treatment are priorities to prevent neurologic injury.

Question 9

A client on continuous positive airway pressure (CPAP) suddenly becomes anxious, tachycardic, and reports a feeling of “air hunger.” The mask seal is intact, and oxygen saturation is falling. Which action should the nurse take FIRST?

Accepted Answer

Answer reason: An acute sense of air hunger with declining oxygenation on CPAP suggests possible intolerance, obstruction, or worsening respiratory status. Immediate removal of the device to assess airway and breathing is the priority before adjustments or consultations.

Question 10

A client receiving IV potassium chloride via infusion pump reports burning pain at the IV site, and erythema is noted along the vein. Which intervention is MOST appropriate?

Accepted Answer

Answer reason: Potassium chloride is irritating to veins. Pain and erythema indicate possible infiltration or phlebitis. The infusion must be stopped immediately to prevent tissue injury before further assessment or interventions.

Question 11

After receiving the first dose of a beta-blocker, a client develops dizziness and a heart rate of 44/min. Blood pressure is decreased from baseline. What should the nurse do FIRST?

Accepted Answer

Answer reason: Symptomatic bradycardia and hypotension indicate an adverse response to beta-blocker therapy. The immediate priority is to withhold further doses and notify the provider for evaluation and orders. Atropine may be required but only with provider direction.

Question 12

A patient taking amiodarone (Cordarone) reports vision changes and shortness of breath. Which finding is the nurse’s highest priority to assess?

Accepted Answer

Answer reason: Amiodarone can cause serious pulmonary toxicity (interstitial pneumonitis/fibrosis), which may present with dyspnea and crackles and can progress to respiratory failure if not detected early. Assessing for pulmonary crackles helps identify a potentially life-threatening adverse drug reaction requiring prompt evaluation and possible discontinuation of the medication. Corneal deposits and blue-gray skin discoloration are typically non-urgent chronic effects, and decreased thyroid function is important but generally not an immediate airway/breathing threat in this presentation.

Question 13

A nurse is caring for a client who has just returned from a colonoscopy with moderate sedation. The client's oxygen saturation is 91%, respiratory rate is 10, and they are drowsy but arousable. What is the nurse's first priority action?

Accepted Answer

Answer reason: After moderate sedation, mild respiratory depression is a common complication; an SpO2 of 91% with RR 10 and arousable drowsiness calls for immediate airway/ventilation support. The first action is to stimulate the patient and prompt deep breathing to improve ventilation and oxygenation while continuing close assessment. Naloxone is reserved for suspected opioid-induced significant respiratory depression or failure to respond to basic measures; restraints and mere documentation do not address the immediate physiologic need.

Question 14

A patient experiences cardiac arrest, and the resuscitation team initiates ventilations using a bag-valve-mask (BVM) resuscitator. The development of which condition during the provision of care would lead the team to suspect that improper BVM technique is being used? Select the correct answer to this question?

Accepted Answer

Answer reason: Improper BVM technique (especially excessive ventilation volume/pressure or poor airway positioning) can cause barotrauma, which may rupture alveoli and lead to pneumothorax during resuscitation. Pneumothorax would be an unexpected complication temporally associated with assisted ventilation and may worsen oxygenation/ventilation and hemodynamics. Rib fracture is more commonly related to chest compressions, esophageal injury is more associated with misplacement of advanced airways or severe gastric insufflation, and hypertension is not a typical indicator of improper BVM technique in cardiac arrest.

Question 15

A laboring client receives IV bolus for epidural but now complains of itching and warmth at the IV site after cefazolin prophylaxis. Hives noted. FHR stable. What is the priority?

Accepted Answer

Answer reason: Itching, warmth, and hives after cefazolin are consistent with an acute hypersensitivity reaction to the medication. The priority is to stop the offending infusion immediately and focus on airway/breathing assessment because allergic reactions can rapidly progress to anaphylaxis even if fetal status is currently stable. The provider should be notified promptly so emergency medications and further orders (e.g., antihistamines/epinephrine as indicated) can be initiated. Continuing the antibiotic or starting oxytocin does not address the immediate safety threat.

Question 16

A patient with COPD is receiving oxygen therapy via nasal cannula at 5 L/min. The nurse notes increasing drowsiness and confusion. What is the nurse’s best action?

Accepted Answer

Answer reason: In a patient with COPD, increasing drowsiness and confusion after higher-flow oxygen suggests CO2 retention (hypercapnia) from excessive supplemental oxygen and worsening ventilatory drive/V-Q mismatch. The safest immediate nursing action is to reduce the oxygen to the lowest level that maintains adequate oxygenation and promptly notify the provider for further evaluation and possible ABG assessment or escalation of ventilatory support. Continuing the same flow or merely reassuring/monitoring risks progression to CO2 narcosis and respiratory failure. Elevating the head of bed can help ventilation, but it does not address the likely oxygen-induced hypercapnia and is not the best action alone.

Question 17

A client receiving haloperidol develops a high fever, muscle rigidity, and confusion. What is the priority nursing action?

Accepted Answer

Answer reason: High fever, severe muscle rigidity, and altered mental status in a client taking haloperidol are classic signs of neuroleptic malignant syndrome (NMS), a life-threatening adverse reaction. The priority action is to stop the offending antipsychotic and urgently notify the provider so definitive treatment (supportive care, possible dantrolene/bromocriptine) can be initiated. Measures like acetaminophen or cooling alone do not address the underlying dopamine blockade and delay critical management. Reorientation is non-urgent and does not treat the emergency.

Question 18

A laboring client on oxytocin has recurrent late decelerations. What is the nurse’s first action?

Accepted Answer

Answer reason: Recurrent late decelerations indicate uteroplacental insufficiency and fetal hypoxia, which can be worsened by oxytocin-stimulated uterine activity. The first nursing intervention is intrauterine resuscitation by repositioning the client to the left lateral position to improve uterine blood flow and maternal cardiac output. Increasing IV fluids and notifying the provider may follow if decelerations persist, but repositioning is the fastest immediate corrective action. Applying an internal fetal scalp electrode improves monitoring accuracy but does not treat the underlying hypoxia.

Question 19

A patient receiving a blood transfusion suddenly develops chills, fever, and back pain 15 minutes after the transfusion begins. What is the nurse’s priority action?

Accepted Answer

Answer reason: Stop the transfusion and maintain IV access with normal saline Chills, fever, and back/flank pain shortly after starting a transfusion are concerning for an acute hemolytic transfusion reaction, which can rapidly progress to shock, DIC, and acute kidney injury. The first priority is to stop the transfusion to prevent further exposure to the offending blood product while keeping the IV line patent with normal saline using new tubing. After stopping, the nurse would then notify the provider and blood bank and follow institutional protocol for assessment and specimen/blood bag handling. Giving antipyretics or checking IDs may be appropriate later but must not delay stopping the transfusion.

Question 20

Bronze baby syndrome is a rare complication of?

Accepted Answer

Answer reason: Bronze baby syndrome is a rare complication seen in neonates with elevated bilirubin levels who receive phototherapy, resulting in a gray-brown discoloration of the skin due to pigment accumulation.

Question 21

Fetal Distress in Labor A nurse notes repetitive late decelerations on the fetal monitor. What is the priority action?

Accepted Answer

Answer reason: Late decelerations indicate uteroplacental insufficiency and fetal hypoxia, which can be worsened by uterine tachysystole. Oxytocin increases contraction frequency and intensity, reducing placental perfusion during contractions, so stopping it immediately removes a common iatrogenic contributor. Other measures (e.g., IV fluid bolus, repositioning, oxygen per protocol) may follow, but halting the infusion is the fastest way to reduce ongoing fetal compromise from excessive contractions.

Question 22

A COPD patient is receiving 4 L/min of oxygen by nasal cannula and becomes increasingly drowsy. What's the best nursing action?

Accepted Answer

Answer reason: Increasing drowsiness in a COPD patient on supplemental oxygen suggests possible CO2 retention and worsening hypercapnia from excessive oxygen administration. The safest immediate nursing response is to titrate oxygen down to the lowest flow that maintains adequate oxygenation while promptly escalating care for further assessment (e.g., ABG, ventilation support). Abruptly stopping oxygen risks severe hypoxemia, while increasing flow may further worsen hypercapnia. Coughing/deep breathing may help ventilation but does not address the likely oxygen-induced hypoventilation/CO2 retention and should not delay notification.

Question 23

A nurse is monitoring a client receiving oxytocin for induction of labor. Which finding requires the immediate nursing action?

Accepted Answer

Answer reason: This pattern suggests uterine tachysystole/hyperstimulation from oxytocin, which can reduce uteroplacental perfusion and rapidly lead to fetal hypoxia and distress. Immediate actions include stopping the oxytocin infusion, repositioning (typically left lateral), increasing IV fluids, and applying oxygen as indicated while notifying the provider. The other findings listed are within expected parameters for labor induction monitoring and do not demand urgent intervention.

Question 24

A nurse is monitoring a client taking amiodarone. Which finding requires immediate attention?

Accepted Answer

Answer reason: This suggests pulmonary toxicity (interstitial pneumonitis/fibrosis), a serious adverse effect of amiodarone that can rapidly compromise oxygenation and requires prompt provider notification and further evaluation (e.g., chest imaging, pulmonary function assessment). In contrast, bradycardia and blurred vision can occur with the medication but are not as immediately life-threatening without additional instability. Nausea is a common, less urgent gastrointestinal effect unless severe or persistent.

Question 25

James, M, 65, was admitted to the Neurology ward with a diagnosis of left-sided ischemic stroke. He is experiencing right-sided weakness, facial droop and slurred speech. He is on tPA and Aspirin. Which clinical sign requires immediate notification to the healthcare provider during tPA infusion?

Accepted Answer

Answer reason: During thrombolytic therapy, any sudden change in neurologic status can indicate intracranial hemorrhage, a life-threatening complication that requires immediate provider notification and urgent evaluation. New confusion represents an acute deterioration from baseline and is more concerning than the patient’s presenting deficits, which may persist early after an ischemic stroke. A BP of 140/88 mmHg is not, by itself, an emergency threshold for tPA monitoring compared with signs of possible bleeding or neurologic decline.

Question 26

The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?

Accepted Answer

Answer reason: After VSD repair, myocardial irritation, conduction pathway disruption, and electrolyte/acid–base shifts can precipitate dysrhythmias that may rapidly compromise cardiac output. Early detection via focused assessment/continuous monitoring allows prompt intervention (e.g., treatment of junctional ectopic tachycardia or heart block) before hemodynamic collapse occurs. The other assessments support perfusion/volume status but are typically less immediately life-threatening than an acute arrhythmia in the immediate post-op period.

Question 27

A nurse is assessing the fetal heart rate (FHR) of a laboring client. The monitor shows late decelerations during contractions. What is the priority nursing action?

Accepted Answer

Answer reason: Late decelerations are associated with uteroplacental insufficiency and fetal hypoxia during contractions, requiring immediate intrauterine resuscitation. Left lateral positioning reduces aortocaval compression, improves maternal cardiac output, and increases uteroplacental perfusion, which can resolve or lessen the decelerations quickly. The other options either delay corrective action or escalate prematurely without first attempting standard, rapid nursing interventions.

Question 28

Oxytocin is administered to Rita to augment labor. What are the first symptoms of water intoxication to observe for during this procedure?

Accepted Answer

Answer reason: Oxytocin can have an antidiuretic effect, increasing the risk of water retention and dilutional hyponatremia, especially when infused with large volumes of hypotonic fluid. Early manifestations of developing hyponatremia/water intoxication are neurologic and GI, commonly including headache, nausea, and vomiting before progressing to confusion, seizures, and coma. The other options are not typical early findings of water intoxication and suggest unrelated conditions (e.g., airway issues or obstetric bleeding/abruption).

Question 29

A patient who received thrombolytic therapy for MI is now reporting new-onset back pain. What is the most concerning?

Accepted Answer

Answer reason: Thrombolytic therapy significantly increases the risk of internal hemorrhage, including retroperitoneal bleeding, which can present with new back pain. Sudden pallor with hypotension indicates hemodynamic instability and possible hemorrhagic shock, requiring immediate assessment and intervention. The other findings are either normal/expected or nonspecific and do not indicate an acute life-threatening complication.

Question 30

Scenario: A nurse is suctioning a trach patient and notices bradycardia. What is the best immediate nursing action?

Accepted Answer

Answer reason: Bradycardia during tracheal suctioning most commonly results from vagal stimulation and/or hypoxia. The immediate priority is to remove the triggering stimulus by stopping suctioning and to correct oxygenation with supplemental oxygen. Continuing suctioning or increasing pressure worsens hypoxia and vagal stimulation, increasing risk of severe dysrhythmia. Atropine may be needed if bradycardia persists, but initial nursing action is to stop suctioning and oxygenate.

Question 31

A hypertensive client is receiving IV labetalol. Which assessment requires priority action?

Accepted Answer

Answer reason: Labetalol has beta-blocking activity and can precipitate bronchospasm, which is an acute airway/breathing threat requiring immediate intervention (stop infusion, assess respiratory status, notify provider, prepare bronchodilator/oxygen as ordered). Wheezing indicates a potentially severe adverse reaction, especially in clients with reactive airway disease, and takes priority over mild bradycardia or expected BP lowering. Fatigue is a common, non-urgent side effect compared with signs of compromised ventilation.

Question 32

A nurse administers oxytocin for labor induction. Which finding requires immediate intervention?

Accepted Answer

Answer reason: Oxytocin can cause uterine tachysystole or hyperstimulation, which decreases uteroplacental perfusion and can rapidly lead to fetal hypoxia. Contractions lasting around 90 seconds suggest excessive uterine activity and warrant immediate actions such as stopping the oxytocin infusion, repositioning the client laterally, and administering IV fluids/oxygen per protocol while assessing fetal status. The other findings are expected/normal in labor (4 cm dilation, baseline FHR 140) or represent a comfort request rather than an urgent safety threat.

Question 33

A client receiving oxytocin infusion has contractions lasting 100 seconds with no resting tone. What is the priority action?

Accepted Answer

Answer reason: Contractions lasting ~100 seconds with no resting tone indicates uterine tachysystole/hyperstimulation, which can rapidly reduce uteroplacental perfusion and cause fetal hypoxia. The first priority is to remove the causative agent by discontinuing oxytocin to decrease contraction frequency and restore uterine relaxation. Supportive measures like left lateral positioning and IV fluid bolus may follow, and escalation (e.g., tocolytic, notify provider) depends on fetal status and response. Preparing for emergency delivery is not the initial action unless there is persistent nonreassuring fetal status despite corrective interventions.

Question 34

A client receiving nitroprusside infusion for hypertensive crisis develops confusion and muscle twitching. What is the nurse’s priority action?

Accepted Answer

Answer reason: These findings suggest possible cyanide toxicity from sodium nitroprusside, a life-threatening adverse effect that can present with neurologic changes (e.g., confusion) and neuromuscular irritability (e.g., twitching), especially with higher doses or prolonged infusions. The immediate priority is to stop the causative infusion to prevent further toxin accumulation and deterioration. After stopping the drug, the nurse should rapidly notify the provider and prepare for supportive management and antidotal therapy per protocol while monitoring hemodynamics and oxygenation. Slowing the infusion or simply documenting delays definitive treatment, and checking sodium does not address the most dangerous likely cause.

Question 35

A 40-week pregnant client is receiving misoprostol for labor induction. What is the most concerning finding?

Accepted Answer

Answer reason: Misoprostol can cause uterine tachysystole/hyperstimulation, which reduces uteroplacental perfusion and increases the risk of fetal hypoxia and uterine rupture. Contractions that are prolonged (>90 seconds) are a warning sign of excessive uterine activity requiring prompt intervention (e.g., stop uterotonic, reposition, IV fluids, consider tocolysis, and notify the provider). The other findings are expected in labor induction: q10-minute contractions are not tachysystole, 3 cm dilation indicates labor progress, and a baseline 140 with accelerations is reassuring.

Question 36

Which activity best reflects the implementation phase of the nursing process for the patient who is newly diagnosed with hypertension?

Accepted Answer

Answer reason: Teaching a newly diagnosed client how to track blood pressure at home is a direct nursing intervention that supports self-management and ongoing evaluation of therapy effectiveness. By contrast, setting goals and outcome criteria is planning, recording OTC medication use is assessment, and formulating human-need statements is part of nursing diagnosis. Education on home monitoring also promotes early recognition of inadequate control or adverse effects and improves adherence to the regimen.

Question 37

A client with a chronic kidney disease is treated on hemodialysis. During the 1 treatment clients blood pressure drops from 150/90 to 80/30 Which action should the nurse take first?

Accepted Answer

Answer reason: The immediate priority is to halt the triggering therapy to prevent further ultrafiltration and worsening shock while quickly initiating supportive measures. Positioning (Trendelenburg-like) and volume expansion may follow, but they are secondary to stopping the treatment that is actively contributing to the hypotension. Simply monitoring would delay urgent stabilization and risks progression to syncope, myocardial ischemia, or cardiac arrest.

Question 38

Fifteen minutes after receiving sulfa ethanozole. A male client report a burning sensation over his abdomen chest and groin. Which intervention is most important for the nurse to implement?

Accepted Answer

Answer reason: The client’s sudden burning sensation shortly after a sulfonamide suggests an early allergic reaction that can progress to respiratory involvement. Assessing for wheezing provides immediate data about bronchoconstriction and helps determine urgency for emergency interventions (e.g., oxygen, epinephrine, rapid response). Reviewing or updating the allergy list is important but is a secondary action after ruling out impending anaphylaxis, and neurologic checks do not address the highest-risk complication.

Question 39

The nurse is caring for a client receiving a blood transfusion who develops urticaria one-half hour after the transfusion has begun. What is the first action the nurse should take?

Accepted Answer

Answer reason: The immediate nursing action is to stop the transfusion to halt progression to more severe reactions such as bronchospasm, hypotension, or anaphylaxis. After stopping, the nurse would maintain IV access with normal saline using new tubing and then assess vital signs and notify the provider/blood bank per protocol. Slowing the rate or giving antihistamine while continuing the transfusion delays definitive management and can worsen patient harm.

Question 40

A 52 year-old client is being transfused with one unit of packed cells. A half hour after the transfusion was initiated, the client complains of chills and headache. Which action should the nurse implement first?

Accepted Answer

Answer reason: Chills and headache developing 30 minutes into a transfusion are early warning signs that must be treated as a possible reaction until proven otherwise. After stopping the transfusion, the nurse would maintain IV access with normal saline using new tubing and then assess vital signs and notify the provider and blood bank per protocol. Simply checking temperature or calling the provider first delays the critical action that reduces antigen exposure and limits harm.

Question 41

Which is a potential complication of central line placement?

Accepted Answer

Answer reason: Central venous catheter insertion (especially subclavian or internal jugular access) risks pleural puncture because the lung apex lies close to the target vessels. Air entry into the pleural space can collapse the lung, causing acute dyspnea, pleuritic chest pain, decreased breath sounds, and hypoxia. For this reason, post-procedure chest x-ray and close respiratory assessment are standard to detect malposition and pneumothorax early. Abdominal organ lacerations are not typical complications of thoracic central line placement and are far less plausible than pleural injury in this context.

Question 42

Which sedation is typically achieved by administering a single, non-IV dose of a long-acting agent?

Accepted Answer

Answer reason: A single non-IV dose of a long-acting sedative is most consistent with producing mild, sustained anxiolysis and drowsiness without the rapid titration needed for deeper levels. Deeper procedural levels generally require IV administration to allow quick onset and careful dose adjustment while monitoring airway and ventilation. General anesthesia implies loss of protective reflexes and typically requires IV induction and/or inhaled agents with airway support. Regional anesthesia is not a sedation level; it is a nerve/neuraxial block technique rather than systemic sedative depth.

Question 43

A nurse is administering a blood transfusion to a client with sickle cell anemia. Which assessment findings would indicate that the client is having a transfusion reaction?

Accepted Answer

Answer reason: The presence of hives and flushing suggests histamine-mediated allergy, while wheezing signals bronchospasm and potential progression toward anaphylaxis requiring immediate stop of transfusion and rapid intervention. Fever alone is more consistent with a febrile nonhemolytic reaction, whereas severe hemolytic reactions more classically include fever with flank/back pain, hypotension, and hemoglobinuria. Compared with rash plus fever without respiratory compromise, the addition of wheezing makes this the most concerning and most specific pattern for a significant transfusion reaction.

Question 44

The HCP has prescribed thrombolytic therapy for the client diagnosed with a myocardial infarction. Which data indicate the medication is effective?

Accepted Answer

Answer reason: Thrombolytics work by dissolving the occluding coronary thrombus, restoring blood flow to previously ischemic myocardium. A classic early sign of successful reperfusion is the appearance of transient ventricular ectopy/accelerated idioventricular rhythm or other reperfusion dysrhythmias as irritable tissue is reoxygenated. Decreasing cardiac enzymes does not occur immediately and biomarkers can continue to rise despite effective reperfusion due to washout and ongoing necrosis. Pain relief and normal blood pressure are nonspecific and can occur from analgesics, nitrates, or hemodynamic support rather than confirming clot lysis.

Question 45

The nurse cares for a postoperative client who has a temperature of 103 degrees Fahrenheit. The nurse knows the causes of postoperative fever include?

Accepted Answer

Answer reason: Fever shortly after surgery can result from an acute transfusion reaction or cytokine-mediated response to transfused blood products. A high temperature in the postoperative period should prompt consideration of therapy-related complications, especially if temporally associated with transfusion and accompanied by chills, flank pain, hypotension, or dark urine. An abscess is a cause of postoperative fever but is typically a later complication developing days after surgery rather than an immediate high fever. Endocrine disorders and a warm environment are not classic etiologies of true postoperative fever compared with infection, atelectasis, thrombophlebitis, or transfusion reactions.

Question 46

A client is admitted with a newly acquired spinal cord injury at the level of T12. He has limited movement of his upper extremities. The nurse anticipates the physician may prescribe which medication?

Accepted Answer

Answer reason: This option best matches the acute neuroprotective intent when new neurologic impairment is present. Diuretics like furosemide or acetazolamide are not standard therapies to improve spinal cord neurologic function after trauma and would risk hypotension that could further compromise cord perfusion. Sodium bicarbonate is reserved for specific acid–base problems (e.g., severe metabolic acidosis) and does not address acute spinal cord edema/inflammation.

Question 47

An 86-year-old client with a stroke in evolution and a history of coronary artery disease is brought to the medical-surgical floor. His medications include isosorbide (Isordil). Which condition is a concern?

Accepted Answer

Answer reason: In an older adult with evolving stroke, drops in blood pressure can reduce cerebral perfusion and worsen neurologic ischemia, making this adverse effect particularly dangerous. The risk is also higher in frail patients and those with baseline low BP or volume depletion, so close BP monitoring and holding the medication per parameters may be required. Other listed conditions are not typical direct adverse effects of nitrates and are less immediately tied to this medication’s primary safety risk.

Question 48

A mother of a neonate receiving phototherapy asks why her child has developed loose stools. Which response by the nurse would be accurate?

Accepted Answer

Answer reason: Phototherapy increases stool frequency and can cause loose, greenish stools due to increased bilirubin breakdown and excretion in the GI tract, which is an expected treatment effect. The priority nursing teaching is to reassure the parent while monitoring hydration status because increased insensible water loss and stools raise dehydration risk. There is no immediate indication that loose stools alone signal infection or formula intolerance in this context. Phototherapy is not discontinued for this expected, manageable effect unless the infant develops concerning signs such as significant dehydration or other complications.

Question 49

The nurse assesses that the client diagnosed with Cushing’s syndrome has an irregular HR, right arm ecchymosis, 4+ pitting edema in the legs, and a blood glucose of 140 mg/dL. Which action should be the nurse’s priority?

Accepted Answer

Answer reason: Severe 4+ pitting edema also raises concern for significant fluid volume excess that may need diagnostic workup and treatment beyond routine monitoring. The blood glucose of 140 mg/dL is mildly elevated and does not represent an immediate life-threatening emergency compared with a new dysrhythmia. Re-weighing the client or measuring abdominal girth are appropriate trend measures but do not address the immediate safety risk signaled by the irregular pulse.

Question 50

A client has been intubated and placed on a ventilator with positive endexpiratory pressure (PEEP). The nurse anticipates that the primary function of PEEP will be to?

Accepted Answer

Answer reason: PEEP maintains positive pressure at end-expiration to prevent alveolar collapse and recruit atelectatic alveoli, which increases functional residual capacity. By stabilizing alveoli, it improves ventilation-perfusion matching and oxygenation without directly increasing delivered oxygen concentration. Bronchiolar “opening” is more characteristic of bronchodilator therapy rather than PEEP’s primary mechanism. A key nursing concern is monitoring for adverse effects from increased intrathoracic pressure such as decreased venous return and hypotension, reflecting therapy response.

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