Question

A nurse is caring for a client on a medical surgical unit.

Answer 1

Correct Answers:

O2 saturation
Chest tube output
Trachea position

Rationale :

Oxygen saturation

🟥 The client’s oxygen saturation has decreased from 92% to 89% on room air, which indicates worsening oxygenation.

🟥 After a lobectomy, declining oxygen saturation may signal respiratory compromise, such as atelectasis, pneumothorax, or tension pneumothorax.

🟥 This drop occurred alongside other concerning findings, increasing the likelihood of an acute postoperative complication.

🟥 Hypoxemia requires immediate provider notification to prevent further respiratory deterioration.

🟥 Early intervention may include oxygen therapy, imaging, or urgent chest tube management.

Chest tube output

🟥 Chest tube drainage abruptly changed from 45 mL to 0 mL, which is abnormal in the immediate postoperative period.

🟥 Sudden cessation of drainage may indicate chest tube obstruction, kinking, clot formation, or dislodgement.

🟥 When combined with falling oxygen saturation and tracheal deviation, this strongly suggests air or blood accumulation in the pleural space.

🟥 Failure of the chest tube to drain can rapidly lead to tension pneumothorax, a life-threatening emergency.

🟥 This finding requires immediate provider notification and rapid intervention.

Trachea position

🟥 The trachea was midline at 0800 and is now deviated at 0920, which is a critical red-flag finding.

🟥 Tracheal deviation indicates increased intrathoracic pressure, often due to tension pneumothorax or hemothorax.

🟥 This is especially concerning after lung surgery and chest tube placement.

🟥 Tracheal deviation can compromise airway patency and cardiac output if not treated promptly.

🟥 This finding alone warrants emergent provider notification, even before other symptoms worsen.

Blood pressure

🟥 BP decreased from 130/80 to 110/60 mm Hg, but this remains within an acceptable range and may reflect analgesic effects or fluid shifts.

🟥 There is no evidence of hypotensive shock at this time.

Respiratory rate

🟥 Respiratory rate increased slightly from 16 to 18/min, which is still within normal limits.

🟥 While it should be monitored, it is not the most urgent finding compared with tracheal deviation and hypoxemia.

Heart rate

🟥 Heart rate increased from 60 to 70/min, which remains within normal adult parameters.

🟥 This change does not indicate acute instability requiring immediate provider notification.

Temperature

🟥 Temperature decreased slightly and does not indicate infection or acute inflammatory response.

🟥 Postoperative temperature variation alone is not an emergency finding in this context.

Urine output

🟥 Urine output of 110 mL over one hour remains adequate renal perfusion.

🟥 There are no signs of acute kidney injury or shock based on urine output alone.

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Answer 2

Correct Answers

Skin assessment [ Fat Embolism Syndrome ]
Neurological status [ Fat Embolism Syndrome ]
Nail bed assessment [ Compartment Syndrome ]
Location of edema [ Compartment Syndrome ; Deep Vein Thrombosis ]
Temperature of extremity [ Compartment Syndrome ]
Respiratory assessment [ Fat Embolism Syndrome ]
Location of pain [ Compartment Syndrome ; Deep Vein Thrombosis ]

Rationale :

Skin assessment- Fat Embolism Syndrome

🟦 Petechial rash on the chest is a classic hallmark of fat embolism syndrome, caused by fat globules lodging in dermal capillaries.

🟦 This finding usually appears 24–72 hours after long-bone fractures, matching the client’s timeline.

🟦 Petechiae are NOT typical of compartment syndrome or DVT.

🟦 The rash most often appears on the chest, neck, axilla, or conjunctiva.

🟦 This sign strongly supports FES over other causes.

Neurological status- Fat Embolism Syndrome

🟦 Decreased alertness, confusion, and difficulty following commands indicate cerebral hypoxia.

🟦 Fat emboli travel to cerebral circulation, causing acute neurologic changes.

🟦 Headache and altered mental status are hallmark findings of FES.

🟦 Neurologic decline is not a feature of isolated DVT or early compartment syndrome.

🟦 This makes FES the primary cause of neurologic symptoms.

Nail bed assessment-Compartment Syndrome

🟦 Cyanotic nail beds indicate reduced arterial perfusion.

🟦 Compartment syndrome causes vascular compression, leading to tissue ischemia.

🟦 Cyanosis reflects impaired oxygen delivery to the extremity.

🟦 DVT usually causes venous congestion, not severe cyanosis.

🟦 Nail bed color change is a classic late ischemic sign of compartment syndrome.

Location of edema-Compartment Syndrome and Deep Vein Thrombosis

🟦 Unilateral leg edema occurs in both CS and DVT.

🟦 In compartment syndrome, edema increases pressure inside a closed muscle compartment.

🟦 In DVT, venous obstruction causes fluid accumulation distal to the clot.

🟦 FES causes systemic findings rather than isolated limb swelling.

🟦 Therefore, edema supports CS and DVT, not FES.

Temperature of extremity- Compartment Syndrome

🟦 A cool extremity indicates arterial compromise.

🟦 Compartment syndrome reduces blood flow due to rising intracompartmental pressure.

🟦 DVT typically presents with warmth, not coolness.

🟦 FES does not cause localized limb temperature changes.

🟦 Coolness strongly points to ischemia from compartment syndrome.

Respiratory assessment- Fat Embolism Syndrome

🟦 Dyspnea, tachypnea, and hypoxia are hallmark features of FES.

🟦 Fat emboli lodge in pulmonary capillaries, causing acute respiratory distress.

🟦 Clear lung sounds do not rule out FES; gas exchange impairment occurs at the capillary level.

🟦 Compartment syndrome does not directly cause respiratory symptoms.

🟦 DVT may cause dyspnea only if it progresses to PE, which is not the primary pattern here.

Location of pain- Compartment Syndrome and Deep Vein Thrombosis

🟦 Severe, unrelenting limb pain is the earliest and most reliable sign of compartment syndrome.

🟦 Pain that is out of proportion and unrelieved by rest is classic for CS.

🟦 DVT also causes localized leg pain, often with swelling.

🟦 FES pain is typically respiratory or neurologic, not focal limb pain.

🟦 Therefore, pain supports CS and DVT.

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Answer 3

Correct Answers:

“I’ve had a fever the last couple of days."

Rationale :

🔴 In systemic lupus erythematosus (SLE), a new fever can indicate infection or a severe disease flare, both of which can become life-threatening.

🔴 Many clients with SLE take immunosuppressants/corticosteroids, which increase infection risk and can mask typical symptoms.

🔴 Fever requires immediate evaluation because untreated infection can rapidly progress to sepsis.

🔴 This finding is prioritized using safety/ABCs, because infection threatens systemic stability before psychosocial or educational needs.

🔴 Early reporting supports timely interventions such as labs, cultures, and treatment to prevent complications.

“I'm concerned because I'm so tired all the time."

🔴 Fatigue is a common chronic manifestation of SLE and is usually not an immediate emergency indicator.

🔴 It should be addressed, but it does not outweigh the urgent safety concern of a new fever.

“I feel like I'm isolated from all my friends now."

🔴 Social isolation is important to assess, but it is not as immediately life-threatening as potential infection.

🔴 Psychosocial support can follow after urgent physiologic threats are ruled out.

“I have a lot of questions about this disease."

🔴 Education is appropriate, but learning needs are not the priority when a symptom suggests possible acute deterioration.

🔴 Teaching is best provided once immediate safety concerns (like fever) are evaluated.

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Answer 4

Correct Answers:

“I changed the floor plan of our home to accommodate my parent's wheelchair."

Rationale :

🟢 Acceptance of a role change is demonstrated by active problem-solving and practical adaptation to new responsibilities.

🟢 Modifying the home shows the client is planning for long-term caregiving needs and creating a safe environment.

🟢 This reflects movement from uncertainty to engagement, indicating the caregiver is integrating the new role into daily life.

🟢 It also demonstrates realistic recognition of the parent’s functional limitations and willingness to support independence.

🟢 Practical preparations are a strong indicator of role acceptance compared with statements focused mainly on distress or frustration.

“I'm so stressed out that it makes it difficult for me to manage everything."

🟢 This reflects caregiver strain and possible ineffective coping rather than acceptance.

🟢 The statement suggests overwhelm without evidence of adaptation or planning.

“At times, I get so frustrated with how to care for my parents."

🟢 Frustration is common, but this statement indicates difficulty coping rather than adjustment.

🟢 It does not demonstrate integration of the role through constructive actions.

“I am learning to take care of my parents as I go."

🟢 This indicates early transition and uncertainty, not full acceptance.

🟢 Acceptance is better demonstrated by concrete actions that reflect commitment and adaptation.

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Answer 5

Correct Answers:

0.5

Rationale :

✍️Order: Enoxaparin 0.75 mg/kg subcutaneously

✍️Client weight: 69.9 kg

✍️Available: 60 mg / 0.6 mL

✍️Step 1: Calculate the required dose (mg)

♦️0.75 mg/kg×69.9 kg

52.425 mg

✍️Step 2: Use the dosage formula

♦️mL to administer=Desired dose (mg)/Dose on hand (mg)×Volume on hand (mL)

✍️Step 3: Plug in the values

♦️52.425/60×0.6

👉 0.52425 mL

✍️Step 4: Round to the nearest tenth

👉 0.5 mL

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Answer 6

Correct Answers:

An IV pump is plugged into an outlet near a sink.

Rationale :

🟠 Electricity near water creates high risk for electrocution and device malfunction.

🟠 Water increases conductivity, so even small spills can cause dangerous current flow.

🟠 Medical devices such as IV pumps should be plugged into outlets away from sinks to prevent shock hazards.

🟠 This situation increases risk for client harm and violates basic home safety standards.

🟠 The nurse should identify this as the priority hazard and recommend relocating equipment to a dry area.

Three-prong plug attached

🟠 A three-prong plug supports grounding and is a safety feature.

🟠 It reduces shock risk compared with two-prong cords.

Protective cover in unused outlet

🟠 Outlet covers are protective, especially in homes with children or vulnerable adults.

🟠 This is a safety measure, not a hazard.

Cord coiled and secured to floor

🟠 Securing cords reduces tripping risk and is generally safer than loose cords.

🟠 The key is ensuring it is not overheating or damaged; the description suggests safe placement.

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Answer 7

Correct Answers:

“Elevate the head of the bed while sleeping."

Rationale :

🔷 Elevating the head of the bed helps prevent reflux by using gravity to keep gastric contents in the stomach.

🔷 This reduces nighttime heartburn, regurgitation, coughing, and throat irritation caused by acid moving into the esophagus.

🔷 It decreases esophageal exposure to acid, helping reduce inflammation and supporting healing of the mucosa.

🔷 This intervention is especially effective for clients with symptoms that worsen when lying flat.

🔷 Head-of-bed elevation is a core nonpharmacologic strategy that improves symptoms without adding medication side effects.

“Lie down after meals."

🔷 Lying down increases reflux because stomach contents can more easily flow back into the esophagus.

🔷 This worsens heartburn and regurgitation, especially soon after eating.

“Eat a snack 1 hour before going to bed."

🔷 Eating close to bedtime increases reflux risk because the stomach is still full when the client lies down.

🔷 GERD teaching encourages avoiding meals/snacks at least 2–3 hours before sleep.

“Eat three large meals each day."

🔷 Large meals increase gastric pressure and delay gastric emptying, worsening reflux.

🔷 Smaller, more frequent meals are preferred to reduce symptoms.

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Answer 8

Correct Answers:

Bounding pulse

Rationale :

🟠 Circulatory overload (TACO) occurs when transfused volume overwhelms the heart, especially in older adults.

🟠 A bounding pulse reflects increased circulating volume and stronger ventricular filling/pressure.

🟠 Overload can progress to pulmonary edema, causing dyspnea, crackles, and increased BP if not addressed.

🟠 Recognizing early signs helps prevent respiratory compromise by slowing/stopping transfusion and notifying the provider.

🟠 This manifestation is consistent with a hypervolemic state rather than a volume-deficient condition.

Hypotension

🟠 Hypotension is more suggestive of an acute transfusion reaction or hypovolemia rather than overload.

🟠 Overload typically causes hypertension, not hypotension.

Flattened jugular veins

🟠 Fluid overload is associated with jugular venous distention, not flattened veins.

🟠 Flattened neck veins suggest low intravascular volume.

Lethargy

🟠 Lethargy is nonspecific and can be caused by anemia, medications, or fatigue.

🟠 It is not a defining early indicator of circulatory overload compared with bounding pulse and respiratory changes.

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Answer 9

Correct Answers:

Report cloudy dialysate drainage to the provider.

Rationale :

⚫ Cloudy dialysate drainage strongly suggests peritonitis, a serious complication of peritoneal dialysis.

⚫ Peritonitis can rapidly progress to systemic infection, so early recognition and reporting are essential.

⚫ Reporting supports prompt collection of dialysate for culture and initiation of antibiotics if prescribed.

⚫ The nurse should also assess for abdominal pain, fever, and rebound tenderness to evaluate severity.

⚫ This action prioritizes client safety because infection is a high-risk emergency in dialysis clients.

Use an infusion pump to deliver the dialysate

⚫ Dialysate is generally infused using gravity to avoid excessive pressure and discomfort.

⚫ Pump infusion can increase risk for complications and is not standard practice.

Warm dialysate in a microwave

⚫ Microwaving can create hot spots and burn the peritoneal lining.

⚫ Dialysate should be warmed using an approved warmer per policy, not a microwave.

Allow dialysate to drain over 1 to 4 hr

⚫ Drain time varies, but prolonged or abnormal drainage should be evaluated for flow problems.

⚫ The priority abnormality in the options is cloudy drainage indicating infection.

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Answer 10

Correct Answers:

Maintain abduction of the affected extremity.

Rationale :

🟢 Maintaining abduction prevents hip dislocation by keeping the femoral head aligned in the acetabulum.

🟢 It avoids positions that increase dislocation risk, especially adduction and internal rotation.

🟢 An abduction pillow is commonly used in the first postoperative days to maintain safe alignment.

🟢 Preventing dislocation protects surgical repair, reduces pain, and prevents the need for additional interventions.

🟢 This is a critical safety measure during early mobility and while repositioning in bed.

Place the affected leg in external rotation

🟢 External rotation can place strain on the joint and is not a recommended goal position after surgery.

🟢 The priority is maintaining neutral alignment with abduction to reduce dislocation risk.

Use incentive spirometer every shift

🟢 Incentive spirometry is important, but “every shift” is too infrequent; it should be used multiple times per hour while awake.

🟢 Hip precautions remain the most critical surgery-specific safety intervention in this question.

Lean forward when rising from a chair

🟢 Leaning forward increases hip flexion beyond safe limits, raising risk of dislocation.

🟢 Hip precautions include avoiding hip flexion greater than 90 degrees.

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Assessment Findings	Compartment Syndrome	Fat Embolism Syndrome	Deep Vein Thrombosis
Skin assessment
Neurological status
Nail bed assessment
Location of edema
Temperature of extremity
Respiratory assessment
Location of pain

Adult Medical Surgical Assessment

No.

1 :
A nurse is caring for a client on a medical surgical unit.

Answer Options

2 :
A nurse is caring for a young adult client in the emergency department.

Correct Answers

3 :
A nurse in a community clinic is caring for a client who has systemic lupus erythematosus (SLE). Which of the following statements by the client should the nurse determine is the priority?

4 :
A nurse is caring for a client who recently assumed the role of caregiver for their aging parents who have chronic illnesses. The nurse should identify that which of the following statements by the client indicates acceptance of the role change?

6 :
A home health nurse is inspecting a client's residence for electrical hazards as part of the agency's quality improvement plan. Which of the following findings should the nurse identify as a safety hazard?

7 :
A nurse is teaching a client who has a new diagnosis of gastroesophageal reflux disease. Which of the following instructions should the nurse include?

8 :
A nurse is assessing an older adult client who is receiving 2 units of packed RBCs. Which of the following manifestations should indicate to the nurse that the client is experiencing circulatory overload?

9 :
A nurse is caring for a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?

10 :
A nurse is caring for a client who is 24 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?

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Adult Medical Surgical Assessment

No.

1 : A nurse is caring for a client on a medical surgical unit.

Answer Options

2 : A nurse is caring for a young adult client in the emergency department.

Correct Answers

3 : A nurse in a community clinic is caring for a client who has systemic lupus erythematosus (SLE). Which of the following statements by the client should the nurse determine is the priority?

4 : A nurse is caring for a client who recently assumed the role of caregiver for their aging parents who have chronic illnesses. The nurse should identify that which of the following statements by the client indicates acceptance of the role change?

6 : A home health nurse is inspecting a client's residence for electrical hazards as part of the agency's quality improvement plan. Which of the following findings should the nurse identify as a safety hazard?

7 : A nurse is teaching a client who has a new diagnosis of gastroesophageal reflux disease. Which of the following instructions should the nurse include?

8 : A nurse is assessing an older adult client who is receiving 2 units of packed RBCs. Which of the following manifestations should indicate to the nurse that the client is experiencing circulatory overload?

9 : A nurse is caring for a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?

10 : A nurse is caring for a client who is 24 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?

1 :
A nurse is caring for a client on a medical surgical unit.

2 :
A nurse is caring for a young adult client in the emergency department.

3 :
A nurse in a community clinic is caring for a client who has systemic lupus erythematosus (SLE). Which of the following statements by the client should the nurse determine is the priority?

4 :
A nurse is caring for a client who recently assumed the role of caregiver for their aging parents who have chronic illnesses. The nurse should identify that which of the following statements by the client indicates acceptance of the role change?

6 :
A home health nurse is inspecting a client's residence for electrical hazards as part of the agency's quality improvement plan. Which of the following findings should the nurse identify as a safety hazard?

7 :
A nurse is teaching a client who has a new diagnosis of gastroesophageal reflux disease. Which of the following instructions should the nurse include?

8 :
A nurse is assessing an older adult client who is receiving 2 units of packed RBCs. Which of the following manifestations should indicate to the nurse that the client is experiencing circulatory overload?

9 :
A nurse is caring for a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?

10 :
A nurse is caring for a client who is 24 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?