Recognition Of Potential Complications - NCLEX Pn

1. A 50-year-old client is receiving IV potassium chloride added to maintenance fluids through a peripheral IV in the left forearm. The client reports burning pain at the site, and the nurse observes blanching and swelling around the catheter. Vital signs: T 36.9°C (98.4°F), HR 92/min, RR 18/min, BP 128/76 mm Hg. Which finding indicates a potential complication?
   Answer: Swelling and blanching at the IV site with burning pain This question tests recognition of potential complications in a client receiving IV potassium. Key symptoms include burning pain, blanching, and swelling at the site, suggesting irritant effects. Swelling and blanching at the IV site with burning pain (A) accurately reflects infiltration or extravasation, risking tissue necrosis. Elevated heart rate post-ambulation (B) is expected; stable blood pressure (C) is normal; warm skin (D) indicates hydration. Early recognition prevents compartment syndrome. Decision-making involves stopping infusion and applying compresses. A transferable strategy is to dilute irritants and monitor sites closely during electrolyte infusions.
2. A 79-year-old client with a history of atrial fibrillation is taking warfarin. The client reports dark stools and dizziness. Vital signs: T 36.9°C (98.4°F), HR 108/min, RR 20/min, BP 98/60 mm Hg. International normalized ratio (INR) is 4.6 (therapeutic range for atrial fibrillation 2.0–3.0). The nurse should monitor for which complication?
   Answer: Gastrointestinal bleeding leading to hypovolemic shock This question tests recognition of potential complications in a client on warfarin with atrial fibrillation. Key symptoms include dark stools, dizziness, tachycardia, hypotension, and elevated INR of 4.6, indicating over-anticoagulation. Gastrointestinal bleeding leading to hypovolemic shock (A) accurately reflects the risk from supratherapeutic INR causing hemorrhage. Pulmonary embolism (B) would occur with subtherapeutic INR; hypertensive crisis (C) is unrelated; hypoglycemia (D) lacks supporting symptoms. Early recognition of bleeding signs and INR deviations prevents shock. Prioritizing reversal agents and monitoring stabilizes the client. A transferable strategy is to assess for occult bleeding and trend INR in all clients on anticoagulants to detect complications early.
3. An 81-year-old client with limited mobility and a history of heart failure is admitted with cough and fatigue. The client has a new onset of fever and pleuritic chest discomfort. Vital signs: T 38.1°C (100.6°F), HR 96/min, RR 24/min, BP 130/68 mm Hg, SpO2 91% on room air. White blood cell count is 13,900/mm3 (normal 4,500–11,000). Which finding indicates a potential complication that requires immediate attention?
   Answer: New confusion with an increasing respiratory rate and an oxygen saturation of 88% New confusion with a rising respiratory rate and an oxygen saturation at 88% are acute changes that suggest hypoxia or reduced brain perfusion. In an older client with heart failure and suspected pneumonia, this pattern may indicate impending respiratory failure and needs immediate attention. A productive cough with thick yellow sputum is an expected pneumonia symptom, not a new acute deterioration. Fever and an elevated white blood cell count are infection markers and, with a blood pressure of 130/68, do not represent the urgent change in the scenario. An elevated white blood cell count with a respiratory rate of 24/min and fatigue reflects admission findings, not new-onset worsening. The immediately urgent finding is the combination of new confusion, worsening respiratory rate, and falling oxygen saturation, not the infection findings that were already present.
4. A 72-year-old client with chronic obstructive pulmonary disease (COPD) is admitted for weakness and decreased appetite. Over the last 24 hours the client developed a new productive cough with yellow-green sputum and increasing shortness of breath. Vital signs: T 38.3°C (101.0°F), HR 104/min, RR 26/min, BP 138/76 mm Hg, SpO2 90% on room air. White blood cell count is 15,200/mm3 (normal 4,500–11,000). Which finding indicates a potential complication that requires immediate attention?
   Answer: New confusion and restlessness with oxygen saturation dropping to 86% despite 2 L/min nasal cannula This question tests recognition of potential complications in a client with COPD experiencing an acute exacerbation. Key symptoms include new productive cough with yellow-green sputum, increasing shortness of breath, elevated temperature, tachycardia, tachypnea, and leukocytosis, indicating infection and respiratory distress. The finding of new confusion and restlessness with oxygen saturation dropping to 86% despite supplemental oxygen accurately reflects emerging hypoxemia and possible acute respiratory failure, requiring immediate intervention. Fine crackles with increased sputum (A) suggest infection but not immediate distress; fever with chills (C) indicates infection without acute decompensation; elevated WBC (D) supports infection but lacks specificity for urgency. Early recognition involves monitoring oxygenation and mental status changes in COPD clients to prevent respiratory failure. Prioritizing airway and breathing assessments facilitates timely escalation of care. A transferable strategy is to trend vital signs and oxygen saturation regularly in clients with chronic respiratory conditions to detect complications early.
5. A 66-year-old client is 6 hours post-operative after an open cholecystectomy. The client reports increasing abdominal pain and feels "lightheaded." Vital signs: T 36.8°C (98.2°F), HR 122/min, RR 22/min, BP 92/58 mm Hg, SpO2 96% on room air. Hemoglobin is 8.9 g/dL (normal 12–16). Which finding indicates a potential complication?
   Answer: Blood pressure 92/58 mm Hg with tachycardia and a decreasing hemoglobin level This question tests recognition of potential complications in a post-operative client after cholecystectomy. Key symptoms include increasing abdominal pain, lightheadedness, tachycardia, hypotension, and decreasing hemoglobin, signaling instability. Blood pressure 92/58 mm Hg with tachycardia and decreasing hemoglobin (B) accurately reflects hemorrhage, a critical post-surgical complication needing immediate attention. Incisional discomfort (A) is expected; absent bowel sounds (C) are normal early post-op; low temperature with dry mucosa (D) may indicate dehydration but not urgency. Early recognition of vital sign changes and lab trends prevents hypovolemic shock. Prioritizing hemodynamic stability guides interventions like fluid resuscitation. A transferable strategy is to monitor post-operative vital signs and hemoglobin levels hourly initially to identify bleeding complications promptly.
6. A 61-year-old client is post-operative day 1 after bowel resection. The client reports increasing pain at the incision and feels "cold." Vital signs: T 39.0°C (102.2°F), HR 118/min, RR 24/min, BP 100/60 mm Hg. White blood cell count is 17,600/mm3 (normal 4,500–11,000). Which symptom suggests an emerging complication?
   Answer: Fever, tachycardia, hypotension, and elevated white blood cell count This question tests recognition of potential complications in a post-operative client after bowel resection. Key symptoms include increasing pain, feeling cold, fever, tachycardia, tachypnea, hypotension, and elevated WBC, suggesting systemic infection. Fever, tachycardia, hypotension, and elevated white blood cell count (A) accurately reflect sepsis from possible anastomotic leak. Incisional pain (B) is expected; no bowel movement (C) is normal early; mild nausea (D) is common. Early recognition prevents septic shock. Decision-making involves antibiotics and fluids. A transferable strategy is to trend inflammatory markers in abdominal surgery clients.
7. An 82-year-old client with chronic obstructive pulmonary disease is admitted from an assisted living facility for weakness and decreased appetite. The client has a new cough and is more confused than baseline. Vital signs: T 100.9°F (38.3°C), HR 102/min, BP 130/70 mm Hg, RR 24/min, SpO2 90% on room air; white blood cell count 13,800/mm³ (normal 4,500–11,000). Which symptom suggests an emerging complication?
   Answer: New confusion with fever and decreased oxygen saturation This question tests recognition of potential complications in elderly clients with chronic lung disease. The key symptoms indicating risk are new confusion, fever (100.9°F), decreased oxygen saturation (90%), tachypnea (RR 24/min), and elevated WBC count (13,800/mm³), which suggest acute respiratory infection. Option A correctly identifies the combination of new confusion with fever and decreased oxygen saturation as indicators of pneumonia, a serious complication in COPD patients requiring prompt antibiotic therapy. Option B (chronic morning cough) represents baseline COPD symptoms, option C (normal blood pressure) is not concerning, and option D (mild tachycardia with activity) is expected. The principle for early recognition is that mental status changes with fever and hypoxemia indicate respiratory infection before severe respiratory failure develops. A transferable monitoring strategy is to compare current symptoms to baseline function, as subtle changes like confusion often precede obvious respiratory distress in elderly clients.
8. A 68-year-old client is 8 hours post-operative after a right total hip arthroplasty. History includes hypertension. The client reports increasing incisional pain and dizziness; the dressing is saturated with bright red drainage. Vital signs: T 98.6°F (37°C), HR 122/min, BP 88/54 mm Hg, RR 22/min, SpO2 96% on room air; hemoglobin 8.1 g/dL (normal 12–16). Which symptom suggests an emerging complication?
   Answer: Tachycardia with hypotension and bright red saturated dressing This question tests recognition of potential complications following hip arthroplasty surgery. The key symptoms indicating risk are tachycardia (HR 122/min), hypotension (BP 88/54), bright red saturated dressing, and low hemoglobin (8.1 g/dL), which together suggest active hemorrhage. Option B correctly identifies the combination of tachycardia with hypotension and bright red saturated dressing as signs of hemorrhagic shock, a life-threatening complication requiring immediate intervention. Option A (warmth and mild itching) represents normal healing responses, option C (normal temperature) is an expected finding, and option D (adequate oxygen saturation) does not indicate complications. The principle for early recognition is that vital sign changes combined with visible bleeding indicate circulatory compromise before complete decompensation occurs. A transferable monitoring strategy is to assess for clusters of symptoms (tachycardia + hypotension + bleeding) rather than isolated findings when evaluating post-operative clients.
9. A 54-year-old client is receiving a continuous heparin infusion for treatment of a deep vein thrombosis. The client reports a new headache and the nurse notes increasing bruising at venipuncture sites. Vital signs: T 98.4°F (36.9°C), HR 98/min, BP 150/92 mm Hg, RR 16/min, SpO2 97% on room air; activated partial thromboplastin time (aPTT) 98 seconds (therapeutic 60–80). The nurse should monitor for which complication?
   Answer: Heparin-induced bleeding, including possible intracranial hemorrhage This question tests recognition of potential complications during heparin therapy for deep vein thrombosis. The key symptoms indicating risk are elevated aPTT (98 seconds, therapeutic 60-80), new headache, increasing bruising at venipuncture sites, and elevated blood pressure, which suggest heparin overdose with bleeding risk. Option A correctly identifies heparin-induced bleeding including possible intracranial hemorrhage as the complication, as headache with hypertension and supratherapeutic aPTT raises concern for cerebral bleeding. Option B (recurrent DVT) would occur with subtherapeutic levels, option C (pulmonary infection) lacks supporting symptoms, and option D (hypoglycemia) is unrelated to heparin therapy. The principle for early recognition is that neurological symptoms with laboratory evidence of over-anticoagulation indicate potential intracranial bleeding before catastrophic hemorrhage. A transferable monitoring strategy is to assess for both obvious bleeding (bruising) and subtle signs (headache, mental status changes) when aPTT exceeds therapeutic range.
10. A 77-year-old client with COPD is being treated for suspected pneumonia. The client becomes more short of breath and is using accessory muscles. Vital signs: T 38.0°C (100.4°F), HR 112/min, RR 30/min, BP 142/80 mm Hg, SpO2 85% on room air. Arterial blood gas shows PaO2 54 mm Hg (normal 80–100). Which symptom suggests an emerging complication?
    Answer: Oxygen saturation 85% with increased work of breathing This question tests recognition of potential complications in a client with COPD and pneumonia. Key symptoms include worsening shortness of breath, accessory muscle use, tachycardia, tachypnea, hypertension, and low PaO2, indicating respiratory distress. Oxygen saturation 85% with increased work of breathing (A) accurately reflects acute hypoxemia and potential respiratory failure. Productive cough (B) suggests infection; fever (C) supports infection; elevated blood pressure (D) may be compensatory. Early recognition of breathing effort and oxygenation prevents arrest. Prioritizing supplemental oxygen and ventilation support is key. A transferable strategy is to perform serial ABGs in clients with chronic lung disease during exacerbations.
11. A 60-year-old client is post-operative day 3 after a colectomy. The nurse notes the incision is red and tender with increasing drainage. Vital signs: T 38.7°C (101.7°F), HR 110/min, RR 22/min, BP 116/70 mm Hg. White blood cell count is 18,200/mm3 (normal 4,500–11,000). Which finding indicates a potential complication?
    Answer: Red, tender incision with fever and elevated white blood cell count This question tests recognition of potential complications in a post-operative client after colectomy. Key symptoms include red, tender incision with drainage, fever, tachycardia, tachypnea, and elevated WBC, suggesting infection. Red, tender incision with fever and elevated white blood cell count (A) accurately reflects surgical site infection. Moderate pain (B), decreased appetite (C), and tachypnea post-activity (D) are expected. Early recognition prevents dehiscence. Decision-making involves wound care and antibiotics. A transferable strategy is to document incision appearance daily in surgical clients.
12. A 28-year-old client with type 1 diabetes received rapid-acting insulin and then began vomiting with inability to keep food down. The client is now breathing rapidly and reports abdominal pain. Vital signs: T 37.8°C (100.0°F), HR 120/min, RR 28/min, BP 100/64 mm Hg. Finger-stick glucose is 356 mg/dL (normal fasting 70–99) and urine ketones are positive. What complication is the client MOST at risk for?
    Answer: Diabetic ketoacidosis with metabolic acidosis This question tests recognition of potential complications in a client with type 1 diabetes after insulin and vomiting. Key symptoms include rapid breathing, abdominal pain, hyperglycemia, and positive ketones, signaling acidosis. Diabetic ketoacidosis with metabolic acidosis (A) accurately reflects the risk from insulin deficiency and ketosis. Hypoglycemia (B) involves low glucose; SIADH (C) causes hyponatremia; pulmonary edema (D) lacks fluid overload signs. Early recognition of Kussmaul breathing and ketones prevents coma. Decision-making includes insulin and fluids. A transferable strategy is to test for ketones in diabetic clients with nausea and hyperglycemia.
13. A 66-year-old client is taking warfarin for atrial fibrillation. The client reports dark, tarry stools and bleeding gums when brushing teeth. Vital signs: T 98.7°F (37.1°C), HR 106/min, BP 102/64 mm Hg, RR 18/min, SpO2 98% on room air; international normalized ratio (INR) 5.2 (therapeutic 2.0–3.0). Which finding indicates a potential complication?
    Answer: INR 5.2 with melena and gum bleeding This question tests recognition of potential complications related to anticoagulation therapy. The key symptoms indicating risk are INR 5.2 (therapeutic range 2.0-3.0), melena (dark tarry stools indicating GI bleeding), and gum bleeding, which together indicate warfarin toxicity with active bleeding. Option A correctly identifies the supratherapeutic INR with bleeding manifestations as the complication requiring immediate vitamin K administration and possible blood products. Option B (normal oxygen saturation), option C (normal temperature), and option D (history of atrial fibrillation) are expected findings that don't indicate complications. The principle for early recognition is that INR above therapeutic range with any bleeding symptoms indicates anticoagulation-related hemorrhage requiring reversal. A transferable monitoring strategy is to correlate INR values with clinical bleeding signs, as even minor bleeding with elevated INR can progress to major hemorrhage.
14. A 58-year-old client is receiving intravenous (IV) 0.9% sodium chloride at 100 mL/hr through a peripheral catheter in the left forearm for dehydration. The client reports pain at the IV site. Vital signs: T 37.0°C (98.6°F), HR 88/min, RR 18/min, BP 126/74 mm Hg. Which symptom suggests an emerging complication?
    Answer: Warmth, redness, and a palpable cord along the vein above the insertion site This question tests recognition of potential complications in a client receiving IV fluids for dehydration. Key symptoms include pain at the IV site in a peripheral catheter infusing normal saline. Warmth, redness, and a palpable cord along the vein (A) accurately reflect phlebitis, an inflammatory complication requiring site discontinuation and monitoring. Increased urine output (B) indicates improving hydration; mild bruising (C) is common without complication; normal capillary refill (D) suggests adequate perfusion. Early recognition of IV site changes prevents progression to infection or thrombosis. Decision-making should prioritize inspecting IV sites frequently during infusions. A transferable strategy is to assess peripheral IV sites every shift for signs of inflammation in all clients on IV therapy.
15. A 39-year-old client with type 2 diabetes is receiving sliding-scale insulin. The client reports increased thirst and frequent urination for 2 days and appears drowsy. Vital signs: T 37.4°C (99.3°F), HR 110/min, RR 22/min, BP 96/62 mm Hg. Finger-stick glucose is 468 mg/dL (normal fasting 70–99). Which complication is the client MOST at risk for?
    Answer: Hyperosmolar hyperglycemic state with severe dehydration This question tests recognition of potential complications in a client with type 2 diabetes on sliding-scale insulin. Key symptoms include increased thirst, frequent urination, drowsiness, tachycardia, tachypnea, hypotension, and glucose of 468 mg/dL. Hyperosmolar hyperglycemic state with severe dehydration (A) accurately reflects the risk in type 2 diabetes with extreme hyperglycemia and dehydration. Hypoglycemia (B) involves low glucose; anaphylaxis (C) lacks allergic signs; hypotension from vagal response (D) is unrelated. Early recognition of osmotic symptoms and vital signs prevents coma. Prioritizing fluid replacement and insulin therapy stabilizes the client. A transferable strategy is to monitor urine output and glucose levels in diabetic clients with dehydration risks.
16. A 57-year-old client is 12 hours post-operative after a thyroidectomy. The client reports tingling around the mouth and in the fingertips. Vital signs: T 36.7°C (98.1°F), HR 96/min, RR 20/min, BP 128/76 mm Hg. Serum calcium is 7.2 mg/dL (normal 8.5–10.5). Which complication is the client MOST at risk for?
    Answer: Hypocalcemia leading to laryngospasm This question tests recognition of potential complications in a post-operative client after thyroidectomy. Key symptoms include perioral and fingertip tingling, tachycardia, tachypnea, and low serum calcium, indicating electrolyte imbalance. Hypocalcemia leading to laryngospasm (A) accurately reflects parathyroid disruption risk. Hemorrhage (B) lacks bleeding signs; hyperglycemia (C) is nonspecific; UTI (D) lacks urinary symptoms. Early recognition prevents tetany. Decision-making includes calcium supplementation. A transferable strategy is to monitor Chvostek's sign in thyroid surgery clients for hypocalcemia.
17. A 79-year-old client with a history of stroke and dysphagia is being fed a mechanical soft diet. The client develops a wet-sounding cough after meals and has coarse crackles in the right lower lung. Vital signs: T 101.2°F (38.4°C), HR 96/min, BP 124/68 mm Hg, RR 22/min, SpO2 91% on room air; white blood cell count 12,900/mm³ (normal 4,500–11,000). What complication is the client MOST at risk for?
    Answer: Aspiration pneumonia This question tests recognition of potential complications in clients with dysphagia and impaired swallowing. The key symptoms indicating risk are wet cough after meals, coarse crackles in right lower lung, fever (101.2°F), and elevated WBC count (12,900/mm³), which strongly suggest aspiration of food/liquids into the lungs. Option A correctly identifies aspiration pneumonia as the complication, evidenced by the temporal relationship between eating and respiratory symptoms plus signs of infection. Option B (pulmonary edema) would present with bilateral crackles and cardiac symptoms, option C (UTI) doesn't explain the respiratory findings, and option D (atelectasis alone) wouldn't cause fever and leukocytosis. The principle for early recognition is that post-meal coughing with unilateral lung findings indicates aspiration before pneumonia fully develops. A transferable monitoring strategy is to observe clients with dysphagia during and after meals for coughing, voice changes, or respiratory distress that suggest aspiration.
18. A 45-year-old client is 2 days post-operative after laparoscopic cholecystectomy. History includes obesity. The client reports increasing incisional tenderness and chills. Vital signs: T 101.8°F (38.8°C), HR 104/min, BP 128/76 mm Hg, RR 18/min, SpO2 98% on room air; white blood cell count 15,200/mm³ (normal 4,500–11,000). Which finding indicates a potential complication?
    Answer: Temperature 101.8°F (38.8°C) with elevated white blood cell count This question tests recognition of potential complications after laparoscopic cholecystectomy. The key symptoms indicating risk are elevated temperature (101.8°F), elevated white blood cell count (15,200/mm³), increasing incisional tenderness, and chills, which suggest surgical site infection. Option A correctly identifies the combination of fever and elevated WBC count as indicators of infection, a complication requiring antibiotic therapy and possible surgical intervention. Option B (pain rated 4/10) represents expected post-operative discomfort, option C (normal blood pressure) is not concerning, and option D (adequate oxygenation) indicates normal respiratory function. The principle for early recognition is that fever combined with leukocytosis in the post-operative period strongly suggests infection before abscess formation or sepsis develops. A transferable monitoring strategy is to trend temperature and laboratory values together with clinical symptoms to identify infectious complications early in surgical clients.
19. A 69-year-old client taking apixaban for atrial fibrillation reports passing bright red blood in the urine. Vital signs: T 36.8°C (98.2°F), HR 102/min, RR 18/min, BP 104/66 mm Hg. Hemoglobin is 10.1 g/dL (normal 12–16). Which symptom suggests an emerging complication?
    Answer: Hematuria with low hemoglobin and borderline hypotension This question tests recognition of potential complications in a client on apixaban for atrial fibrillation. Key symptoms include hematuria, tachycardia, low-normal blood pressure, and decreased hemoglobin, signaling blood loss. Hematuria with low hemoglobin and borderline hypotension (A) accurately reflects bleeding complication from anticoagulation. Tachycardia post-activity (B) is expected; normal temperature (C) and respiratory rate (D) are unrelated. Early recognition prevents anemia. Decision-making involves holding medication and monitoring. A transferable strategy is to check for visible blood in urine or stool in anticoagulated clients.
20. A 74-year-old client taking warfarin for deep vein thrombosis reports bleeding gums when brushing teeth and has multiple new bruises on the arms. Vital signs: T 36.8°C (98.2°F), HR 86/min, RR 16/min, BP 118/72 mm Hg. INR is 3.9 (therapeutic range for deep vein thrombosis 2.0–3.0). Which finding indicates a potential complication?
    Answer: Bleeding gums and easy bruising with INR above therapeutic range This question tests recognition of potential complications in a client on warfarin for DVT. Key symptoms include bleeding gums, bruising, and INR of 3.9, indicating over-anticoagulation. Bleeding gums and easy bruising with INR above therapeutic range (A) accurately reflects hemorrhage risk. Stable heart rate (B), blood pressure (C), and temperature (D) are normal. Early recognition prevents major bleeding. Prioritizing vitamin K or holding doses stabilizes coagulation. A transferable strategy is to monitor for mucosal bleeding in clients on oral anticoagulants.

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