A nurse is planning care for a client 12 hours after a cesarean birth under spinal anesthesia. Which interventions should the nurse include?
Select all that apply.
Help the client to sit at the bedside and walk as soon as prescribed
Show the client how to hold a pillow against the incision when she coughs and breathes deeply
Palpate the fundus gently and assess the lochia
Keep the client flat in bed until bowel sounds return
Assess the incision dressing and the urine output
Show the answers and explanation
Answers: A, B, C and E.
A – Help the client to sit at the bedside and walk as soon as prescribed
B – Show the client how to hold a pillow against the incision when she coughs and breathes deeply
C – Palpate the fundus gently and assess the lochia
E – Assess the incision dressing and the urine output
Topic: post-cesarean care
After cesarean birth the client has the risks of any abdominal surgery plus those of the postpartum period: thromboembolism, atelectasis, hemorrhage, urinary retention and ileus. Early ambulation, splinted deep breathing, fundal and lochia checks, and monitoring of the incision and urine output address these risks.
Why the others are wrong
D – Bed rest until bowel sounds return increases the risk of thromboembolism, atelectasis and ileus; early ambulation helps bowel function return.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
2Question
A nurse is assessing a client 3 days after a cesarean birth that followed a long labor with membranes ruptured for many hours. Which findings suggest a uterine infection and should be reported?
Select all that apply.
Temperature of 38.5 C (101.3 F)
Urine output of 2,500 mL in the past 24 hours
Lochia with a foul odor
Cramping that becomes stronger while she breastfeeds
Uterine tenderness that is increasing rather than easing
Show the answers and explanation
Answers: A, C and E.
A – Temperature of 38.5 C (101.3 F)
C – Lochia with a foul odor
E – Uterine tenderness that is increasing rather than easing
Topic: postpartum endometritis
Endometritis typically appears in the first days after birth with fever beyond the first 24 hours, foul-smelling lochia, and a tender, sometimes poorly involuting uterus, often with tachycardia and malaise. Cesarean birth, long labor and prolonged rupture of membranes are the main risk factors.
Why the others are wrong
B – Postpartum diuresis is expected as the extra fluid of pregnancy is excreted.
D – Afterpains during breastfeeding come from oxytocin release and are normal.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
3Question
On the first day after a right lower lobectomy through a thoracotomy incision, a client takes shallow breaths and refuses to cough, rating incisional pain as 8 on a scale of 0 to 10. Breath sounds are diminished at the bases. Which action should the nurse take first?
Explain that coughing is needed to prevent pneumonia and insist that the client try now.
Let the client rest and try the breathing exercises again at the end of the shift.
Ask the provider for a cough suppressant so that the client is more comfortable.
Give the prescribed analgesic, then help the client splint the incision to deep breathe and cough.
Show the answer and explanation
Answer: D. Give the prescribed analgesic, then help the client splint the incision to deep breathe and cough.
Topic: pain and airway clearance after thoracotomy
Thoracotomy pain is severe and makes the client guard against deep breaths and coughing, which leads to retained secretions, atelectasis and pneumonia. Relieving pain first makes effective coughing possible, and splinting the incision supports it.
Why the others are wrong
A – Teaching alone will not overcome severe pain; the client cannot comply until the pain is controlled.
B – Waiting allows secretions to collect and atelectasis to progress.
C – Suppressing the cough after lung surgery causes secretions to be retained.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
4Question
The nurse is assessing a client 4 hours after a total thyroidectomy. Which finding requires immediate intervention?
A hoarse, weak voice when the client answers questions
A sore throat that is worse on swallowing
Incisional pain rated 4 on a 0-to-10 scale
A statement that the dressing feels tight, with a new high-pitched sound on breathing in
Show the answer and explanation
Answer: D. A statement that the dressing feels tight, with a new high-pitched sound on breathing in
Topic: thyroidectomy hematoma and airway
Bleeding into the closed space of the neck forms a hematoma that compresses the trachea. A sensation of tightness or pressure with new stridor means the airway is narrowing; this is an emergency that needs the surgeon and airway equipment at once and may require the incision to be opened at the bedside.
Why the others are wrong
A – Mild hoarseness is common from intubation and swelling near the laryngeal nerves; it is monitored, and the client is still moving air well enough to speak.
B – A sore throat is expected after intubation and neck surgery.
C – Moderate incisional pain is expected and is treated with the prescribed analgesic.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
5Question
A client returned from a transurethral resection of the prostate 3 hours ago with continuous bladder irrigation. The prescription is to adjust the irrigation to keep the drainage light pink. The drainage is flowing freely but has changed from light pink to red with several small clots. Which action does the nurse take first?
Slow the irrigation and measure the output hourly.
Clamp the irrigation and apply traction to the catheter.
Increase the flow rate of the irrigation.
Remove the catheter and insert a smaller one.
Show the answer and explanation
Answer: C. Increase the flow rate of the irrigation.
Topic: continuous bladder irrigation after TURP
The purpose of continuous irrigation is to wash blood out of the bladder before it clots and blocks the catheter. When the drainage darkens or small clots appear while the catheter is still draining, the nurse increases the irrigation rate as prescribed and reassesses; bleeding that does not clear, or bright red drainage with many clots, is then reported.
Why the others are wrong
A – Slowing the irrigation lets blood sit in the bladder and clot, which blocks the catheter.
B – Clamping stops the washout and lets clots form; catheter traction is a surgeon's decision, not a first nursing step.
D – The catheter is not removed after prostate surgery without a prescription; reinsertion can injure the surgical site.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
6Question
A 3-month-old infant returns to the unit after repair of a cleft lip. Which interventions should the nurse include in the plan of care?
Select all that apply.
Place the infant prone so that secretions drain from the mouth
Apply elbow immobilizers, removing them one at a time at regular intervals while the infant is supervised
Position the infant on the back or upright in an infant seat
Leave crusts on the suture line, because they protect the incision
Cleanse the suture line gently after feedings as prescribed
Show the answers and explanation
Answers: B, C and E.
B – Apply elbow immobilizers, removing them one at a time at regular intervals while the infant is supervised
C – Position the infant on the back or upright in an infant seat
E – Cleanse the suture line gently after feedings as prescribed
Topic: cleft lip post-repair care
After cleft lip repair the aim is to protect the suture line from trauma, tension and crusting. The infant is kept off the face, the hands are kept away with elbow immobilizers that are released regularly for skin checks and movement, and the incision is cleaned gently after feeding so that crusts do not form.
Why the others are wrong
A – Prone positioning lets the infant rub the repaired lip against the mattress.
D – Crusts on the suture line increase scarring and infection risk; the line is gently cleansed to prevent crusting.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
7Question
A newborn with a myelomeningocele is awaiting surgical closure. Which interventions should the nurse include in the plan of care?
Select all that apply.
Position the newborn prone with the hips slightly flexed
Cover the sac with a sterile, moist, non-adherent dressing
Fasten the diaper snugly over the sac to protect it
Use latex-free gloves and equipment
Measure the temperature rectally every four hours
Measure the head circumference daily and assess the fontanels
Show the answers and explanation
Answers: A, B, D and F.
A – Position the newborn prone with the hips slightly flexed
B – Cover the sac with a sterile, moist, non-adherent dressing
D – Use latex-free gloves and equipment
F – Measure the head circumference daily and assess the fontanels
Topic: myelomeningocele preoperative care
Before closure the sac must be kept intact, moist and clean, so the newborn lies prone, the sac is covered with a sterile moist dressing and stool is kept away from it. Children with spina bifida are at high risk of latex allergy, so latex is avoided from birth. Hydrocephalus commonly accompanies the defect and is watched for by head measurement.
Why the others are wrong
C – A diaper over the sac puts pressure on it and holds urine and stool against it; the area is left open with a protective drape below the sac.
E – Rectal temperatures are avoided because anal sphincter tone is often poor and the probe can injure or cause prolapse of the rectum.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
8Question
Five days after abdominal surgery a client coughs and says, 'Something just gave way.' The nurse finds the incision open with a loop of bowel protruding. Which action should the nurse take first?
Gently push the bowel back into the abdomen with a sterile gloved hand
Stay with the client, call for help and cover the bowel with sterile dressings moistened with sterile normal saline
Apply an abdominal binder firmly over the wound
Leave the room to telephone the surgeon and bring the dressing cart
Show the answer and explanation
Answer: B. Stay with the client, call for help and cover the bowel with sterile dressings moistened with sterile normal saline
Topic: wound evisceration
Evisceration is a surgical emergency. The nurse remains with the client, summons help, keeps the exposed bowel moist and protected with sterile saline-soaked dressings and places the client in low Fowler's position with the knees bent to reduce tension on the abdomen while the surgeon is notified and the client is prepared for surgery.
Why the others are wrong
A – Pushing the bowel back can injure it and carry contamination into the abdomen; replacement is done in surgery.
C – Firm pressure from a binder over protruding bowel can cut off its blood supply.
D – The surgeon must be notified, but the nurse does not leave the client; help is called to the bedside.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
9Question
Twenty minutes into general anesthesia with an inhaled agent and succinylcholine, a client develops rigidity of the jaw, a pulse of 138/min, a rapidly rising end-tidal carbon dioxide level and a climbing temperature. Which medication should the nurse prepare to give?
Dantrolene
Acetaminophen
Naloxone
Neostigmine
Show the answer and explanation
Answer: A. Dantrolene
Topic: malignant hyperthermia
Jaw rigidity, tachycardia, a rising end-tidal carbon dioxide and a rising temperature after these triggering agents indicate malignant hyperthermia. The triggering agents are stopped, dantrolene is given to halt the release of calcium in skeletal muscle, and the client is cooled and given 100% oxygen.
Why the others are wrong
B – The temperature rise comes from muscle hypermetabolism, not from the hypothalamic set point, so an antipyretic does not treat it.
C – Naloxone reverses opioids; this is not an opioid effect.
D – Neostigmine reverses nondepolarizing muscle relaxants and does not stop the muscle crisis of malignant hyperthermia.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
10Question
A client arrives in the postanesthesia care unit after general anesthesia, lying flat with oxygen by face mask. The client is very drowsy and has snoring respirations, and the oxygen saturation has fallen from 97% to 88%. Which action should the nurse take first?
Increase the oxygen flow rate
Give naloxone
Call the anesthesia provider and wait at the bedside
Open the airway with a jaw-thrust or chin-lift and stimulate the client
Show the answer and explanation
Answer: D. Open the airway with a jaw-thrust or chin-lift and stimulate the client
Topic: postoperative airway obstruction
Snoring respirations in a sedated client mean that the relaxed tongue is partly blocking the airway. Lifting the jaw moves the tongue forward and restores airflow, and stimulating the client improves breathing effort; this takes seconds and comes before any other step.
Why the others are wrong
A – Extra oxygen does not reach the lungs while the tongue is blocking the airway; the obstruction must be relieved first.
B – Naloxone may be needed if opioid-induced respiratory depression is found, but the obstructed airway is opened first and the drug requires a prescription.
C – Help may be needed, but waiting while the airway stays obstructed allows the hypoxia to worsen.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
11Question
Three days after a total hip replacement, a client suddenly reports sharp chest pain that is worse on breathing in, and shortness of breath. The pulse is 126/min, respirations are 30/min and oxygen saturation is 86% on room air. Which action should the nurse take first?
Raise the head of the bed and apply oxygen
Examine both calves for swelling and tenderness
Coach the client to use the incentive spirometer
Give the prescribed analgesic for the chest pain
Show the answer and explanation
Answer: A. Raise the head of the bed and apply oxygen
Topic: pulmonary embolism
Sudden pleuritic chest pain, dyspnea, tachycardia and hypoxemia a few days after major orthopedic surgery suggest pulmonary embolism. The first action supports oxygenation: upright position and oxygen; the nurse then stays with the client, activates the rapid response team and notifies the provider.
Why the others are wrong
B – Calf findings may point to the source of the clot, but looking for them does not treat hypoxemia and can wait.
C – An incentive spirometer prevents and treats atelectasis; it is not the response to sudden severe hypoxemia.
D – Treating the pain without addressing oxygenation leaves the life-threatening problem in place.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
12Question
The nurse teaches a client to use an incentive spirometer after abdominal surgery. Which statement by the client shows that the teaching was understood?
'I blow into the mouthpiece as hard and as fast as I can.'
'I use it only when I begin to feel short of breath.'
'I breathe in slowly and deeply through the mouthpiece, hold my breath for a few seconds, then breathe out.'
'I lie flat on my back while I use it so that my incision is not strained.'
Show the answer and explanation
Answer: C. 'I breathe in slowly and deeply through the mouthpiece, hold my breath for a few seconds, then breathe out.'
Topic: incentive spirometer teaching
An incentive spirometer encourages a slow, sustained maximal inhalation, which opens the alveoli and prevents atelectasis. It is used sitting upright, about ten times every hour while awake, with a brief breath-hold at the end of each inhalation, and with the incision splinted for coughing afterward.
Why the others are wrong
A – Forceful blowing out describes a peak flow meter; the spirometer works on a slow breath in.
B – It is used regularly every hour while awake to prevent atelectasis, not kept for when symptoms appear.
D – Lying flat limits lung expansion; the client sits upright and supports the incision with a pillow.
Written for the Medical Exam YouTube channel and answered blind by a second AI model before publication.
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Nursing