Recognising and preventing complications

70 NCLEX-RN practice questions on Recognising and preventing complications, part of Reduction of Risk Potential. The first 25 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

1. Question 1 · Medium · Matrix

   Before going home after a midline laparotomy, a client talks about protecting the abdominal incision from splitting open. Which remarks show sound understanding and which call for more teaching?

   For each row, choose: Shows understanding / Needs more teaching

   1. I can pick up my 25-pound grandson as soon as I'm home.
   2. If I feel something pop or give way, I'll lie down and call.
   3. I'll start sit-ups next week to firm up my stomach.
   4. I'll hug a folded pillow against my belly whenever I cough.
   5. If I get constipated, I'll hold my breath and push hard.
   6. I'll try to eat eggs, fish or beans at every meal.

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   Answer:

   • I can pick up my 25-pound grandson as soon as I'm home.: Needs more teaching
   • If I feel something pop or give way, I'll lie down and call.: Shows understanding
   • I'll start sit-ups next week to firm up my stomach.: Needs more teaching
   • I'll hug a folded pillow against my belly whenever I cough.: Shows understanding
   • If I get constipated, I'll hold my breath and push hard.: Needs more teaching
   • I'll try to eat eggs, fish or beans at every meal.: Shows understanding

   This tests evaluate outcomes (CJMM). Teaching to prevent dehiscence centres on splinting, avoiding lifting and straining, adequate protein and reporting a sudden pulling or popping sensation.

   • I can pick up my 25-pound grandson as soon as I'm home.: Heavy lifting strains the fascia; lifting limits from the surgeon apply for several weeks.
   • If I feel something pop or give way, I'll lie down and call.: A popping sensation can signal dehiscence and needs urgent review.
   • I'll start sit-ups next week to firm up my stomach.: Abdominal exercises are avoided until the surgeon allows them.
   • I'll hug a folded pillow against my belly whenever I cough.: Splinting supports the wound edges against the pressure of coughing.
   • If I get constipated, I'll hold my breath and push hard.: Straining raises abdominal pressure; a stool softener and fluids are safer.
   • I'll try to eat eggs, fish or beans at every meal.: Protein supplies the amino acids needed for collagen and wound strength.

2. Question 2 · Medium · Select all that apply

   In the post-anesthesia care unit, a client develops jaw rigidity, a heart rate of 138/min and a temperature rising to 103.8°F (39.9°C). Malignant hyperthermia is suspected. Which actions should the nurse anticipate?

   1. AStopping any triggering anesthetic agent
   2. BGiving dantrolene IV
   3. CMonitoring potassium and the cardiac rhythm
   4. DApplying ice packs and giving cold IV saline
   5. EGiving 100% oxygen at a high flow
   6. FCovering the client with a warmed blanket

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   Answer: A, B, C, D, E

   This tests generate solutions (CJMM). Malignant hyperthermia is a hypermetabolic crisis: stop the trigger, give dantrolene, give oxygen, cool the client and treat hyperkalemia and acidosis.

   • F: Warming worsens hyperthermia; the client needs cooling.

3. Question 3 · Easy · Select all that apply

   A client is recovering on the surgical unit after an open abdominal hysterectomy. Which measures help prevent deep vein thrombosis?

   1. AMassaging the calves firmly if they feel tight
   2. BWalking in the hallway on the evening of surgery if able
   3. CDoing ankle pumps and foot circles every hour while awake
   4. DPlacing a pillow under both knees for comfort
   5. EWearing intermittent pneumatic compression sleeves in bed
   6. FSitting with the legs crossed when up in the chair

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   Answer: B, C, E

   This tests generate solutions (CJMM). Venous stasis is the main surgical risk for DVT, so prevention relies on movement and mechanical compression; anything that compresses the popliteal or calf veins, or rubs a possible clot, adds risk.

   • A: Massage can dislodge an unrecognised clot and is never used for prevention.
   • D: Knee gatching compresses the popliteal veins and slows venous return.
   • F: Crossing the legs compresses veins and increases stasis.

4. Question 4 · Medium · Select all that apply

   The nurse is screening clients on the morning of elective surgery under general anesthesia. Which clients have an increased risk of aspiration on induction?

   1. AA client with severe reflux and a hiatal hernia
   2. BA client with nothing by mouth since midnight
   3. CA client who drank clear apple juice 3 hours ago
   4. DA client who ate a fried breakfast 3 hours ago
   5. EA client who takes weekly semaglutide injections
   6. FA client with diabetic gastroparesis

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   Answer: A, D, E, F

   This tests recognise cues (CJMM). Food in the stomach, delayed gastric emptying and reflux raise aspiration risk; these clients are reported to the anesthesia provider before induction.

   • B: An overnight fast meets the usual fasting guidance.
   • C: Clear liquids are allowed up to 2 hours before anesthesia in healthy adults.

5. Question 5 · Medium · Select all that apply

   A client is going home on enoxaparin injections after a hip replacement. Which findings should the client report to the provider promptly?

   1. ABlack, tarry stools
   2. BOne calf becoming swollen and painful
   3. CMild itching along the healing incision
   4. DA small bruise at the injection site
   5. EBrief stinging while giving the injection
   6. FSudden breathlessness or chest pain

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   Answer: A, B, F

   This tests evaluate outcomes (CJMM). Teaching covers signs of bleeding and of breakthrough VTE; small injection-site bruises and brief stinging are expected.

   • C: Itching is a normal part of wound healing.
   • D: Small bruises at subcutaneous injection sites are common.
   • E: Mild stinging is a known, harmless effect of enoxaparin.

6. Question 6 · Hard · Matrix

   The nurse is comparing two hypotensive postoperative clients. For each finding, indicate whether it more strongly suggests hypovolemic shock from bleeding or septic shock.

   For each row, choose: Hypovolemic shock / Septic shock

   1. Wound drain with 300 mL bright red blood in an hour
   2. Temperature of 102.4°F (39.1°C) with foul wound drainage
   3. Hemoglobin falling from 12.4 to 8.6 g/dL
   4. Warm, flushed skin with bounding pulses
   5. Cool, pale, clammy skin with flat neck veins
   6. White blood cell count of 19,500/mm3

   Answer and explanation in LearnFree account

7. Question 7 · Hard · Matrix

   The RN is planning care on a surgical unit with an LPN/VN and assistive personnel. For each task, indicate who should perform it.

   For each row, choose: RN only / LPN/VN / Assistive personnel

   1. Assess a client's new report of calf pain
   2. Apply sequential compression devices
   3. Reinforce incentive spirometer teaching
   4. Give scheduled subcutaneous enoxaparin to a stable client
   5. Evaluate a client's response to IV dextrose
   6. Measure and record urine output from a catheter bag

   Answer and explanation in LearnFree account

8. Question 8 · Medium · Matrix

   The nurse is assessing a client after a total knee replacement. For each finding, indicate whether it suggests a deep vein thrombosis or a pulmonary embolism.

   For each row, choose: Deep vein thrombosis / Pulmonary embolism

   1. Calf tenderness when the vein is palpated
   2. Sharp chest pain that worsens on inspiration
   3. Coughing up blood-streaked sputum
   4. Sudden shortness of breath at rest
   5. One calf is 3 cm larger than the other
   6. Warmth and redness along the back of the calf

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9. Question 9 · Medium · Matrix

   On the evening of an open bowel resection, a client weighing 70 kg has these findings on the surgical ward. Which ones are normal early recovery, and which need action?

   For each row, choose: Expected / Requires follow-up

   1. BP 86/50 mm Hg, preoperatively 128/76
   2. Heart rate of 122/min
   3. Urine output 20 mL/hour for 2 hours
   4. Small serosanguineous spot on the dressing
   5. Temperature of 99.7°F (37.6°C)
   6. Hypoactive bowel sounds

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10. Question 10 · Easy · Matrix

    The nurse is reviewing the history of clients scheduled for abdominal surgery. For each factor, indicate whether it increases the risk of wound dehiscence.

    For each row, choose: Increases risk / Does not increase risk

    1. Walks a mile every day before surgery
    2. Serum albumin of 2.4 g/dL
    3. Body mass index of 42
    4. Long-term daily prednisone for asthma
    5. Hemoglobin A1C of 5.4%
    6. Chronic smoker's cough

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11. Question 11 · Hard · Matrix

    A client who had a hip replacement 3 days ago has new respiratory symptoms. For each finding, indicate whether it more strongly supports pulmonary embolism or pneumonia.

    For each row, choose: Pulmonary embolism / Pneumonia

    1. Cough with thick yellow sputum
    2. Clear breath sounds despite SpO2 86%
    3. Temperature 102.2°F (39°C) with coarse crackles
    4. Swollen, tender left calf
    5. Consolidation of the right lower lobe on chest x-ray
    6. Dyspnea that began within minutes while straining on the commode

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12. Question 12 · Medium · Select all that apply

    A client with a recent stroke has dysphagia and is on aspiration precautions. Which tasks can the RN delegate to assistive personnel?

    1. AReporting coughing or choking during meals
    2. BPerforming the bedside swallow screen
    3. CGiving oral care before and after meals
    4. DTeaching the client the chin-tuck technique
    5. EKeeping the head of the bed upright during and after meals
    6. FDeciding the right liquid thickness for each meal

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13. Question 13 · Hard · Select all that apply

    A client has had a nasogastric feeding tube in place for 3 days, and its position was confirmed by x-ray on insertion. Which findings suggest the tube may have moved and that feeding should be held?

    1. ATube marking at the nostril has moved from 55 cm to 47 cm
    2. BAspirate pH of 4 that looks grassy green
    3. CGastric residual volume of 90 mL
    4. DNo air sound heard when air is injected
    5. ENew coughing whenever the tube is flushed

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14. Question 14 · Medium · Matrix

    A client with a fractured tibia in a long-leg splint reports severe, worsening pain, and the nurse suspects compartment syndrome. For each action, indicate whether it is indicated or contraindicated.

    For each row, choose: Indicated / Contraindicated

    1. Keep the leg at the level of the heart
    2. Notify the provider of the findings at once
    3. Check pain on passive stretch of the toes
    4. Give a second opioid dose and reassess in an hour
    5. Apply an ice pack over the swollen calf
    6. Raise the leg on two pillows above the heart

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15. Question 15 · Hard · Select all that apply

    A client with obstructive sleep apnea is receiving morphine by PCA after abdominal surgery. Which actions reduce the risk of opioid-induced respiratory depression?

    1. ATeaching family to press the PCA button while he sleeps
    2. BPositioning him flat on his back to rest
    3. CUsing continuous pulse oximetry or capnography
    4. DHaving the client use his own CPAP while sleeping
    5. EAsking for a basal PCA infusion for better sleep
    6. FChecking the sedation level with a sedation scale

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16. Question 16 · Medium · Matrix

    The nurse is teaching a new graduate about compartment syndrome. For each finding, indicate whether it is usually an early or a late sign.

    For each row, choose: Early sign / Late sign

    1. Pale, cool skin over the foot
    2. Pain when the toes are passively extended
    3. Numbness and tingling in the foot
    4. Pain out of proportion to the injury
    5. Inability to move the toes
    6. Absent pedal pulse

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17. Question 17 · Hard · Matrix

    The nurse uses the quick SOFA (qSOFA) score to screen postoperative clients with suspected infection. For each client, indicate whether the screen is positive (2 or more criteria) or negative.

    For each row, choose: Positive screen / Negative screen

    1. HR 124/min, T 102.6°F (39.2°C), RR 20/min, BP 118/70, alert
    2. RR 26/min, systolic BP 132 mm Hg, oriented
    3. RR 20/min, systolic BP 96 mm Hg, newly confused
    4. RR 24/min, systolic BP 98 mm Hg, alert and oriented
    5. RR 22/min, systolic BP 104 mm Hg, GCS 14

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18. Question 18 · Hard · Select all that apply

    At the start of the shift, the nurse reviews these postoperative clients. Which findings require immediate action?

    1. ADay 1 after laparoscopic cholecystectomy: right shoulder pain 4/10
    2. BDay 0 after hysterectomy: temperature 99.6°F (37.6°C)
    3. CDay 1 after knee replacement: 40 mL serosanguineous drainage in 8 hours
    4. DDay 3 after colectomy: pink, watery fluid soaking the dressing after a cough
    5. EDay 1 after laminectomy on PCA: hard to rouse, RR 8/min
    6. FDay 2 after hip replacement: new anxiety and SpO2 89%

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19. Question 19 · Medium · Select all that apply

    An 84-year-old client is on day 2 after repair of a hip fracture and has a urinary catheter. Which findings are consistent with early sepsis even though the client has no fever?

    1. ATemperature of 96.3°F (35.7°C)
    2. BSystolic BP 98 mm Hg, usually 140
    3. CRespiratory rate of 24/min
    4. DNew confusion about where she is
    5. ESpO2 of 96% on room air
    6. FHeart rate of 104/min

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20. Question 20 · Medium · Select all that apply

    A client receiving continuous enteral feeding through a nasogastric tube is checked during the night shift. Which findings suggest the client may have aspirated?

    1. ANew crackles over the right lower lobe
    2. BNew coughing and gurgling voice during the feeding
    3. CSpO2 falling from 96% to 89%
    4. DGastric residual volume of 120 mL
    5. EMild fullness after a formula rate increase
    6. FActive bowel sounds in all four quadrants

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21. Question 21 · Easy · Select all that apply

    A client with diabetes who takes insulin is learning about hypoglycemia. Which symptoms are early warning signs of a low blood glucose?

    1. ADeep, rapid breathing with fruity breath
    2. BA pounding or racing heartbeat
    3. CShakiness or trembling of the hands
    4. DPassing large amounts of urine
    5. ESudden strong hunger
    6. FSweating with cool, clammy skin

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22. Question 22 · Hard · Matrix

    The nurse is reviewing data on postoperative clients. For each finding, indicate whether it should be reported to the surgeon now or monitored as part of routine care.

    For each row, choose: Report now / Continue to monitor

    1. Abdominal drain: 200 mL bright red blood in the last hour
    2. Heart rate rising from 88 to 118/min over 2 hours with restlessness
    3. Day 1 hemoglobin 7.8 g/dL, preoperatively 11.6 g/dL
    4. Day 1 hemoglobin 10.9 g/dL, preoperatively 12.1 g/dL
    5. Knee drain: 60 mL serosanguineous fluid over 8 hours
    6. Dried blood spot on the dressing, unchanged in 4 hours

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23. Question 23 · Hard · Select all that apply

    The nurse checks the urine output of postoperative clients against a minimum of 0.5 mL/kg/hour. Which clients are below that minimum?

    1. A70 kg, 120 mL over 4 hours
    2. B90 kg, 200 mL over 5 hours
    3. C50 kg, 80 mL over 2 hours
    4. D60 kg, 150 mL over 4 hours
    5. E80 kg, 250 mL over 6 hours
    6. F100 kg, 140 mL over 3 hours

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24. Question 24 · Hard · Select all that apply

    A client with sepsis has received a 30 mL/kg crystalloid bolus. Which findings indicate progression to septic shock or worsening hypoperfusion?

    1. ALactate rising from 2.8 to 4.6 mmol/L
    2. BMean arterial pressure of 58 mm Hg after the bolus
    3. CWarm, flushed skin
    4. DUrine output of 0.2 mL/kg/hour
    5. EMottled skin over both knees
    6. FTemperature of 100.9°F (38.3°C)

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25. Question 25 · Hard · Select all that apply

    A client has an epidural catheter for analgesia after abdominal surgery and has received enoxaparin. Which findings should the nurse report immediately?

    1. ABP 112/70 mm Hg, preoperatively 118/74
    2. BNew, severe back pain near the catheter site
    3. CNew loss of bladder or bowel control
    4. DGeneralised itching
    5. ENumbness of both legs spreading above the expected level
    6. FNew weakness of both legs

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