Recognition Of Potential Complications - NCLEX Pn

1. What complication should be suspected with chest pain unrelieved by rest and diaphoresis?

   Acute coronary syndrome (myocardial infarction). Persistent chest pain with sympathetic activation like sweating suggests myocardial ischemia or infarction requiring urgent evaluation.

2. What assessment finding is most concerning for hypovolemic shock in an adult?

   Tachycardia with hypotension and cool, clammy skin. These signs reflect compensatory tachycardia from volume loss, reduced perfusion causing hypotension, and vasoconstriction leading to cool, clammy skin in hypovolemic shock.

3. What complication should be suspected when a patient on warfarin has black, tarry stools?

   Gastrointestinal bleeding. Warfarin anticoagulation increases bleeding risk, with melena indicating upper GI hemorrhage from altered clotting.

4. What is the most concerning assessment finding for digoxin toxicity?

   Bradycardia with nausea and visual halos. Digoxin toxicity affects the heart and nervous system, causing slowed heart rate, gastrointestinal upset, and visual disturbances like halos.

5. Which assessment finding suggests aspiration in a patient receiving tube feedings?

   New cough with crackles and oxygen desaturation. Aspiration introduces feedings into the lungs, causing inflammation that manifests as cough, adventitious sounds, and impaired gas exchange.

6. What finding indicates possible anaphylaxis after a new medication is started?

   Wheezing or stridor with hypotension. Anaphylaxis involves bronchoconstriction causing wheezing or stridor and systemic vasodilation leading to hypotension as part of a severe allergic response.

7. Which ECG-related complication is most associated with hyperkalemia?

   Peaked T waves. Elevated potassium alters cardiac repolarization, producing tall, peaked T waves on ECG as an early indicator of hyperkalemia.

8. What is the key sign of hypoglycemia in a patient receiving insulin?

   Diaphoresis with shakiness and confusion. Hypoglycemia triggers adrenergic responses like sweating and tremors, alongside neuroglycopenic effects causing confusion.

9. Which assessment finding most suggests acute urinary retention?

   Suprapubic distention with inability to void. Urinary retention leads to bladder overdistention, palpable suprapubically, with failure to empty despite the urge or effort.

10. What complication should be suspected with bright red blood and clots in urine after TURP?

    Hemorrhage. Bright red hematuria with clots post-TURP indicates active bleeding from the surgical site in the prostate or bladder.

11. Which finding is most consistent with acute stroke rather than hypoglycemia?

    Unilateral facial droop with arm drift. Focal neurologic deficits like hemiparesis distinguish stroke from diffuse metabolic issues like hypoglycemia, which lack laterality.

12. Which symptom suggests lithium toxicity requiring prompt evaluation?

    Coarse tremor and ataxia. Lithium toxicity impairs neurologic function, producing gross motor disturbances like tremor and ataxia that necessitate immediate intervention.

13. What is the priority complication to suspect with sudden unilateral leg swelling and pain?

    Deep vein thrombosis (DVT). Sudden unilateral leg symptoms suggest venous thrombosis obstructing blood flow, leading to swelling and pain in the affected limb.

14. What complication is suggested by fever, flank pain, and cloudy foul-smelling urine?

    Acute pyelonephritis. Pyelonephritis is an ascending urinary tract infection reaching the kidneys, causing systemic fever, localized pain, and urine changes.

15. Which symptom most strongly suggests pulmonary embolism in a postoperative patient?

    Sudden dyspnea with pleuritic chest pain. Pulmonary embolism often presents with abrupt shortness of breath and chest pain worsened by inspiration due to vascular occlusion in the lungs.

16. Which clinical finding is most consistent with diabetic ketoacidosis (DKA)?

    Kussmaul respirations with fruity breath odor. DKA involves metabolic acidosis prompting deep, rapid breathing for compensation and ketosis producing a characteristic fruity acetone odor.

17. What pupil change is most concerning for acute neurologic deterioration?

    New unequal pupils (anisocoria). Unequal pupils indicate potential brain herniation or focal lesions compressing the oculomotor nerve, signaling urgent neurologic compromise.

18. What complication should be suspected with stridor and drooling in a child?

    Acute airway obstruction. Stridor indicates upper airway narrowing, while drooling suggests inability to swallow secretions, often from epiglottitis or foreign body in children.

19. What is the most concerning sign of wound dehiscence?

    Sudden serosanguineous drainage from incision. A sudden gush of serosanguineous fluid signals separation of wound edges, increasing risk for evisceration if not addressed promptly.

20. What complication is suggested by bowel sounds absent and abdominal distention after surgery?

    Paralytic ileus. Postoperative ileus causes temporary paralysis of intestinal motility, resulting in absent bowel sounds and gaseous distention.

21. What complication should be suspected with muscle cramps and a positive Trousseau sign?

    Hypocalcemia. Low calcium levels increase neuromuscular excitability, leading to cramps and carpopedal spasm elicited by Trousseau sign.

22. Which finding most strongly indicates postoperative hemorrhage?

    Increasing drainage with falling blood pressure. Increased drainage suggests ongoing blood loss, while hypotension reflects hypovolemia from hemorrhage in the postoperative period.

23. Which assessment finding suggests increased intracranial pressure (ICP)?

    Decreasing level of consciousness. Rising ICP compresses brain tissue, progressively impairing arousal and awareness, making altered consciousness a hallmark sign.

24. Which finding indicates possible heparin-induced thrombocytopenia (HIT)?

    Platelet count drop with new thrombosis. HIT involves antibody-mediated platelet destruction and activation, paradoxically causing thrombocytopenia alongside new clot formation.

25. Which change in level of consciousness is an early sign of hypoxia?

    Restlessness or new-onset confusion. Hypoxia initially impairs cerebral function, manifesting as behavioral changes like restlessness or confusion before more severe symptoms develop.

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