Question 1

The clinic nurse collects information from a parent and assesses the pediatric client one week after hospital discharge for removal of a brain tumor. Which finding best suggests the child may have developed a complication?

Accepted Answer

Answer reason: This finding is clinically significant because it can rapidly lead to dehydration, hypernatremia, and hemodynamic instability if not recognized and treated. Occasional headaches can be expected during recovery and are less specific without signs of increased intracranial pressure (e.g., vomiting, lethargy). Palpable shunt tubing can be a normal assessment finding, and needing crutches reflects mobility needs rather than a direct postoperative intracranial complication.

Question 2

A nurse in the intensive care unit is caring for a critically ill client with an intra-aortic balloon pump (IABP). An IABP provides mechanical support for the client’s failing heart. Even when inserted properly, the client is at risk for complications. Which complication can result from the use of an IABP?

Accepted Answer

Answer reason: IABP therapy involves placement and cycling of a balloon within the descending thoracic aorta, so the major procedure-related risks are vascular injury and disruption of the aortic wall. An intimal tear from catheter/balloon trauma can precipitate dissection, particularly in fragile or atherosclerotic vessels. Other common IABP complications also stem from arterial access (e.g., limb ischemia, bleeding), which aligns with an aortic complication rather than intrathoracic air leak or pericardial fluid accumulation. Pneumothorax and cardiac tamponade are more characteristic of central line placement or cardiac procedures, not an aortic balloon device.

Question 3

A client in labor is receiving oxytocin (Pitocin) to augment her labor. A nurse notes a change in her contraction pattern. The fetal heart monitor indicates that her contractions are lasting 2 minutes, with a notable rise in the baseline. Based on this finding, which action is the priority?

Accepted Answer

Answer reason: Uterine tachysystole from oxytocin can reduce uteroplacental perfusion by limiting uterine relaxation time, increasing the risk of fetal hypoxia. Contractions lasting about 2 minutes indicate excessive uterine activity and require immediate reduction of the provoking agent. Decreasing the infusion is the most direct, fastest way to correct the medication-induced complication and is a nursing action that can be done without delay. Oxygen and left-lateral positioning can be supportive measures, but they do not address the primary cause as effectively as reducing the oxytocin dose.

Question 4

A nursing home resident returns to the facility after receiving a hemodialysis treatment. Which symptom observed by the charge nurse suggests that the client has developed disequilibrium syndrome?

Accepted Answer

Answer reason: The expected early findings are headache, nausea, restlessness, confusion, and progression to decreased level of consciousness or seizures. Respiratory symptoms and peripheral edema more strongly suggest fluid overload rather than an acute osmotic cerebral process. Loss of a fistula thrill indicates access thrombosis/occlusion, which is a vascular access complication rather than disequilibrium syndrome.

Question 5

The nurse is caring for the client requiring positive pressure mechanical ventilation. The client has been resisting the ventilator-assisted breaths, and the client’s BP has been steadily decreasing. Which intervention should the nurse implement?

Accepted Answer

Answer reason: Patient–ventilator dyssynchrony increases work of breathing and can trigger high intrathoracic pressures during positive-pressure ventilation, which reduces venous return and can worsen hypotension. Providing ordered sedation can improve synchrony, reduce agitation and excessive inspiratory efforts, and thereby decrease cardiopulmonary stress while supporting adequate ventilation. Adjusting ventilator rate is not the first nursing action when the primary issue is resistance/dyssynchrony with hemodynamic decline, and it may not resolve the underlying agitation. Prone positioning is mainly for severe oxygenation failure (e.g., ARDS) and is not an immediate fix for dyssynchrony with falling BP; IV aminophylline is not indicated without evidence of bronchospasm and carries arrhythmia/toxicity risks.

Question 6

The client with a primary diagnosis of liver cancer with metastases to the lung is hospitalized with severe dyspnea. The nurse is preparing the client for radiation of the upper chest. Which nursing conclusion about the purpose of radiation therapy for this client is correct?

Accepted Answer

Answer reason: Upper chest irradiation for lung metastases can decrease airway/mediastinal compression and inflammation contributing to severe dyspnea, improving comfort and respiratory function. Curative or definitive control is unlikely when there is a primary liver malignancy with metastatic spread, making “cure and control” conclusions inappropriate. Radiation does not prevent future cancer development; it is used to treat existing malignant tissue and manage complications from it.

Question 7

The nurse is suctioning the pediatric client who just had cardiac surgery. The nurse observes tachypnea, the use of accessory muscles to breathe, and restlessness. Which action should be taken by the nurse?

Accepted Answer

Answer reason: These findings indicate acute respiratory distress and possible hypoxemia triggered or worsened by suctioning, which can transiently decrease oxygenation and increase vagal stimulation in a vulnerable post–cardiac surgery child. The immediate nursing priority is to stop the provoking procedure, support oxygenation/ventilation, and reassess closely for deterioration. Notifying the HCP is warranted because the change may signal a complication requiring prompt evaluation and additional interventions. Continuing suctioning risks worsening hypoxia and increasing work of breathing; preparing for a chest tube is premature without evidence of pneumothorax or effusion.

Question 8

The child with aplastic anemia has had human leukocyte antigen (HLA) typing, evaluation of organ function, and laboratory studies completed as an outpatient. Which action should the nurse plan to implement first when the child is admitted to a transplant center for a hematopoietic stem cell transplant?

Accepted Answer

Answer reason: Hematopoietic stem cell transplant requires a conditioning regimen (typically high-dose chemotherapy, sometimes with radiation) to ablate the recipient’s marrow and suppress immunity so donor cells can engraft. On admission to the transplant center, initiating preparation for this planned, time-sensitive conditioning phase is the key first step that drives the rest of the care pathway. Airborne precautions are not routine for transplant patients; the focus is protective/neutropenic precautions (private room, strict hand hygiene, often HEPA filtration) rather than airborne isolation unless a specific pathogen is suspected. Irradiated blood products (not food) are used to prevent transfusion-associated graft-versus-host disease, and central line patency is important but is a task that follows from, rather than defines, the immediate transplant-conditioning plan.

Question 9

A client is being treated with bilevel positive airway pressure (BiPAP). The nurse anticipates that the use of BiPAP will?

Accepted Answer

Answer reason: BiPAP delivers two levels of positive airway pressure—higher inspiratory pressure to augment ventilation and lower expiratory pressure to maintain alveolar recruitment and improve oxygenation. This dual-pressure support reduces work of breathing and improves CO2 clearance compared with a single continuous pressure mode. Option C describes an expiratory pressure effect consistent with PEEP/CPAP but misses the key BiPAP feature of separate inspiratory support. Option A is incorrect because BiPAP is a pressure modality and does not inherently provide 100% oxygen; FiO2 is set independently and typically titrated to target saturation.

Question 10

There are four patients on the busy labor and delivery unit undergoing induction of labor with oxytocin. The nurse supervisor for the unit is reviewing the patients. Which patient situation would require the supervising nurse to alert the bedside nurse to take immediate action?

Accepted Answer

Answer reason: Oxytocin can cause uterine tachysystole, which reduces uteroplacental perfusion and can rapidly lead to fetal compromise. Contractions occurring about every 90 seconds are abnormally frequent and warrant immediate nursing interventions such as stopping the infusion, repositioning, and intrauterine resuscitation per protocol. The fetal heart rate may still be within the normal baseline range early on, so waiting for decelerations is unsafe. By contrast, contractions every 5–10 minutes with reassuring fetal heart rates are typical patterns during labor progression and are not the most urgent finding.

Question 11

Which is the highest priority in the post ECT care?

Accepted Answer

Answer reason: Post-procedure nursing care therefore focuses first on assessing respiratory rate/effort, oxygenation, and protective reflexes until the client is stable. Confusion and need for reorientation are expected transient effects of ECT, but they are secondary once ABCs are assured. Documentation is important but is not time-critical compared with preventing respiratory compromise.

Question 12

A nurse is caring for a postoperative client who is receiving IV hydromorphone every 3 hours PRN for pain. One hour after administration, the client becomes difficult to arouse, with a respiratory rate of 8 breaths per minute and oxygen saturation of 89% on room air. Which action should the nurse take first?

Accepted Answer

Answer reason: The priority is to reverse life-threatening opioid-induced respiratory depression before progressive hypoxemia and apnea occur. Bradypnea (RR 8) with decreased level of consciousness soon after IV hydromorphone strongly indicates opioid toxicity as the immediate cause. Naloxone is the specific antagonist that rapidly restores ventilatory drive and arousal, addressing the underlying problem rather than only supporting oxygenation. Applying oxygen or stimulating the client may provide temporary support but does not correct the opioid effect, and notifying the provider should follow urgent stabilization measures.

Question 13

The nurse should teach a client that a normal local tissue response to radiation is?

Accepted Answer

Answer reason: Mild erythema is an expected early reaction and is typically managed with gentle skin care and monitoring. Pustules suggest infection (not a normal response) and require assessment. Sloughing of multiple skin layers represents a more severe burn/ulceration and is not considered a normal expected local reaction.

Question 14

The nurse cares for a client diagnosed with end-stage renal disease who just returned from initial hemodialysis. Which of the following assessment findings is of the highest concern?

Accepted Answer

Answer reason: New-onset neurologic symptoms after an initial hemodialysis session raise concern for dialysis disequilibrium syndrome from rapid osmotic shifts causing cerebral edema. Headache with nausea can be an early warning for worsening neurologic compromise and potential seizures, requiring prompt assessment and intervention. Scant blood at the AV fistula is common post-needle removal if minimal and controlled, but becomes highest concern only with active bleeding or hematoma expansion. A potassium of 3.7 mEq/L is normal, and a hemoglobin of 8.8 g/dL is expected in ESRD and generally represents a chronic issue rather than an acute post-dialysis emergency.

Question 15

The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the most appropriate nursing action?

Accepted Answer

Answer reason: These post-hemodialysis symptoms (headache, nausea, marked restlessness) are concerning for dialysis disequilibrium syndrome, an acute complication from rapid osmotic shifts leading to cerebral edema and rising intracranial pressure. This is an unexpected and potentially life-threatening response that requires immediate medical evaluation and possible changes to dialysis parameters or supportive therapy. Nursing measures like elevating the head of the bed or giving an antiemetic may provide limited symptomatic relief but do not address the underlying neurologic emergency and risk of deterioration (e.g., seizures). Close monitoring is important, but escalation to the provider is the priority action to prevent progression and initiate definitive management.

Question 16

The nurse cares for a client following a parathyroidectomy. The nurse alerts the provider to which assessment finding?

Accepted Answer

Answer reason: Post-parathyroidectomy patients are at risk for hypocalcemia due to reduced parathyroid hormone, which can cause neuromuscular irritability. Perioral and distal extremity tingling is an early sign that can precede tetany, laryngospasm, or seizures and requires prompt evaluation and calcium replacement as indicated. This finding represents a potentially dangerous postoperative complication rather than an expected recovery symptom. In contrast, mild-to-moderate incisional discomfort and vesicular breath sounds are expected, and moderate serosanguineous drain output can be normal early post-op if not rapidly increasing or bright red.

Question 17

Your patient becomes restless and tells you she has a headache and feels nauseous during hemodialysis. Which complication do you suspect?

Accepted Answer

Answer reason: Early findings commonly include headache, nausea/vomiting, restlessness, and confusion occurring during or shortly after hemodialysis, especially when shifts are rapid. Air embolism more typically causes sudden dyspnea, chest pain, hypotension, and altered mental status rather than a headache-nausea cluster. Infection is usually associated with fever/chills or access-site changes and is not an immediate intradialytic syndrome like this.

Question 18

You have administered a mildly sedating medication to promote sleep. An hour after your client was given this medication, you client is jittery and hyperactive. What has most likely occurred?

Accepted Answer

Answer reason: Becoming jittery and hyperactive after a sedating medication is a classic paradoxical-type response, indicating an unusual individual sensitivity rather than the typical side-effect profile. This fits better than a general adverse effect, which usually refers to known, predictable undesirable effects seen in some patients at therapeutic doses. There is no information suggesting an incorrect drug/dose/route/time to support a medication error, and the scenario does not describe serious permanent harm required to label it a sentinel event.

Question 19

A nurse is caring for a client who has a prescription for fluoxetine and who reports self-administering st. John’s wort daily for the past 2 weeks, which of the following findings should the nurse report to the provider as an indication of serotonin syndrome?

Accepted Answer

Answer reason: John’s wort. It commonly presents with altered mental status (e.g., agitation, confusion, hallucinations), autonomic instability (hyperthermia, diaphoresis, hypertension), and neuromuscular findings (tremor, clonus, hyperreflexia). This client’s concurrent use creates a high-risk interaction, so new-onset perceptual disturbances should be urgently reported for evaluation and discontinuation of serotonergic drugs. Decreased temperature is opposite of the typical hyperthermia, and constipation/hyposexuality are more consistent with non-emergent medication side effects rather than toxic serotonin excess.

Question 20

Assessing a patient following IV morphine administration, the nurse notes cold, clammy skin; a pulse of 41 beats/min; respirations of 11 breaths/min; and constricted pupils. Which medication will the patient likely need next?

Accepted Answer

Answer reason: The immediate priority is to reverse opioid effects on the central nervous system and respiratory drive using an opioid antagonist. Naloxone competitively displaces opioids from receptors and can rapidly restore ventilation when given promptly. NSAIDs like meloxicam do not address opioid-induced respiratory depression, and other analgesics (pentazocine, propoxyphene) would not reverse toxicity and could worsen sedation or respiratory compromise.

Question 21

The nurse cares for a client diagnosed with end-stage renal disease who just returned from initial hemodialysis. Which of the following assessment findings is of the highest concern?

Accepted Answer

Answer reason: New-onset headache and nausea after an initial hemodialysis treatment raises concern for dialysis disequilibrium syndrome from rapid solute shifts causing cerebral edema. This can progress to confusion, seizures, and coma, making it a time-sensitive complication requiring immediate assessment and provider notification. In contrast, scant blood at the access site can occur after needle removal and is less concerning if there is no active bleeding or hemodynamic instability. A potassium of 4.9 mEq/L is high-normal and not an acute post-dialysis emergency, and anemia (hemoglobin 8.8) is common in ESRD and typically managed chronically rather than emergently in this context.

Question 22

A client with lung cancer who wears a subcutaneous morphine sulfate patch for pain is short of breath and is difficult to arouse. When performing a head to toe assessment, the nurse discovers four analgesic patches on the client's body. Which intervention should the nurse implement first?

Accepted Answer

Answer reason: The priority is to stop continued opioid delivery when opioid toxicity is suspected, because transdermal systems can keep absorbing and worsen respiratory depression. Having multiple patches indicates an excessive dose and the fastest way to reduce ongoing exposure is immediate removal of every patch and cleansing the sites as appropriate. Oxygen may be needed, but it does not address the cause and the client can continue to deteriorate while the drug continues to absorb. A narcotic antagonist can be required, but removing the source comes first to prevent re-sedation after reversal and to limit further absorption.

Question 23

A client receiving mechanical ventilation has arterial blood gas results of pH 7.5, PaO2 95mmHg, PaCO2 30 mmHg, and HCO3- 22. Which action should be a priority for this client?

Accepted Answer

Answer reason: The ABG shows alkalemia with low PaCO2 and normal HCO3-, indicating acute respiratory alkalosis from excessive minute ventilation on the ventilator. The priority intervention is to reduce alveolar ventilation to raise PaCO2 toward normal and correct the pH. Reducing tidal volume directly decreases minute ventilation (or can be used along with rate adjustments depending on settings) and is an appropriate nursing/clinical action to address ventilator-induced hyperventilation. Increasing respiratory rate would worsen hypocapnia, and increasing oxygen is unnecessary because oxygenation is adequate (PaO2 95). Stopping mechanical ventilation is unsafe and not indicated when a titration of settings can correct the problem.

Question 24

A client receiving a transfusion of packed red blood cells (PRBCs) begins to vomit. The client's blood pressure is 90/50mm Hg from a baseline of 125/78mm Hg. The client's temperature is 100.8°F (38.2°C) orally from a baseline of 99.2°F (37.3°C) orally. The nurse determines that the client may be experiencing which complication of a blood transfusion?

Accepted Answer

Answer reason: The abrupt blood pressure drop with a new fever strongly supports sepsis-related systemic inflammatory response rather than a benign febrile nonhemolytic reaction. Circulatory overload would more often cause hypertension, dyspnea, crackles, and JVD rather than hypotension and fever. Delayed transfusion reactions occur days to weeks later and would not explain the immediate vomiting and hypotension during transfusion.

Question 25

The pt newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the pt is at risk for disequilibrium syndrome, the nurse should assess the pt during dialysis for which associated manifestations?

Accepted Answer

Answer reason: The hallmark findings are neurologic—headache, confusion or decreased level of consciousness, and neuromuscular irritability that can progress to seizures. Twitching reflects early CNS irritability and worsening cerebral edema risk during or shortly after dialysis. The other options emphasize temperature or hemodynamic patterns that are more consistent with dialysis-related hypotension, infection, or volume changes rather than this neurologic syndrome.

Question 26

The nurse is caring for a client recovering from a thyroidectomy to treat hyperthyroidism. Which assessment finding would require the nurse to immediately notify the health care provider?

Accepted Answer

Answer reason: Temperature increase to 100 F (37.8 C) from 98.9 F (37.2 C) 30 minutes prior A rapid, new temperature rise shortly after thyroidectomy can signal developing thyroid storm or an acute postoperative complication and requires urgent evaluation. The pattern (increase within 30 minutes) is more concerning than a low-grade fever alone because it suggests escalating hypermetabolic activity in a client treated for hyperthyroidism. Early recognition and provider notification allow prompt interventions (e.g., beta-blockade, antithyroid therapy, supportive measures) before progression to severe tachyarrhythmias, hypertension, and hyperthermia. Small drainage on the dressing, throat soreness/odynophagia, and incisional pain are common postoperative findings that are typically monitored and managed unless accompanied by airway compromise or uncontrolled bleeding.

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Unexpected Response to Therapies Practice Test 2

Unexpected Response to Therapies NCLEX Practice Test

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The clinic nurse collects information from a parent and assesses the pediatric client one week after hospital discharge for removal of a brain tumor. Which finding best suggests the child may have developed a complication?

A client in labor is receiving oxytocin (Pitocin) to augment her labor. A nurse notes a change in her contraction pattern. The fetal heart monitor indicates that her contractions are lasting 2 minutes, with a notable rise in the baseline. Based on this finding, which action is the priority?

A nursing home resident returns to the facility after receiving a hemodialysis treatment. Which symptom observed by the charge nurse suggests that the client has developed disequilibrium syndrome?

The nurse is caring for the client requiring positive pressure mechanical ventilation. The client has been resisting the ventilator-assisted breaths, and the client’s BP has been steadily decreasing. Which intervention should the nurse implement?

The client with a primary diagnosis of liver cancer with metastases to the lung is hospitalized with severe dyspnea. The nurse is preparing the client for radiation of the upper chest. Which nursing conclusion about the purpose of radiation therapy for this client is correct?

The nurse is suctioning the pediatric client who just had cardiac surgery. The nurse observes tachypnea, the use of accessory muscles to breathe, and restlessness. Which action should be taken by the nurse?

A client is being treated with bilevel positive airway pressure (BiPAP). The nurse anticipates that the use of BiPAP will?

There are four patients on the busy labor and delivery unit undergoing induction of labor with oxytocin. The nurse supervisor for the unit is reviewing the patients. Which patient situation would require the supervising nurse to alert the bedside nurse to take immediate action?

Which is the highest priority in the post ECT care?

The nurse should teach a client that a normal local tissue response to radiation is?

The nurse cares for a client diagnosed with end-stage renal disease who just returned from initial hemodialysis. Which of the following assessment findings is of the highest concern?

The nurse is performing an assessment on a client who has returned from the dialysis unit following hemodialysis. The client is complaining of headache and nausea and is extremely restless. Which is the most appropriate nursing action?

The nurse cares for a client following a parathyroidectomy. The nurse alerts the provider to which assessment finding?

Your patient becomes restless and tells you she has a headache and feels nauseous during hemodialysis. Which complication do you suspect?

You have administered a mildly sedating medication to promote sleep. An hour after your client was given this medication, you client is jittery and hyperactive. What has most likely occurred?

A nurse is caring for a client who has a prescription for fluoxetine and who reports self-administering st. John’s wort daily for the past 2 weeks, which of the following findings should the nurse report to the provider as an indication of serotonin syndrome?

Assessing a patient following IV morphine administration, the nurse notes cold, clammy skin; a pulse of 41 beats/min; respirations of 11 breaths/min; and constricted pupils. Which medication will the patient likely need next?

The nurse cares for a client diagnosed with end-stage renal disease who just returned from initial hemodialysis. Which of the following assessment findings is of the highest concern?

A client with lung cancer who wears a subcutaneous morphine sulfate patch for pain is short of breath and is difficult to arouse. When performing a head to toe assessment, the nurse discovers four analgesic patches on the client's body. Which intervention should the nurse implement first?

A client receiving mechanical ventilation has arterial blood gas results of pH 7.5, PaO2 95mmHg, PaCO2 30 mmHg, and HCO3- 22. Which action should be a priority for this client?

The pt newly diagnosed with chronic kidney disease recently has begun hemodialysis. Knowing that the pt is at risk for disequilibrium syndrome, the nurse should assess the pt during dialysis for which associated manifestations?

The nurse is caring for a client recovering from a thyroidectomy to treat hyperthyroidism. Which assessment finding would require the nurse to immediately notify the health care provider?

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