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Questions 149

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Extract:


Question 1 of 5

The nurse in a long-term care setting wants to delegate the task of ambulating an elderly client with a walker to an unlicensed assistive personnel (UAP). Before delegating a task to the UAP, the nurse should first ensure which of the following is accomplished?

Correct Answer: D

Rationale: The nurse must ensure the UAP is credentialed and trained per facility policy to perform the task safely, as this ensures competence and compliance with regulations.

Question 2 of 5

The nurse is performing a physical assessment on a newly admitted client. The last step in the physical assessment is:

Correct Answer: D

Rationale: Palpation is the last step in a physical assessment, following inspection, auscultation, and percussion, to avoid altering findings with touch.

Question 3 of 5

When assessing the client with acute arterial occlusion, the nurse would expect to find:

Correct Answer: B

Rationale: Acute arterial occlusion causes ischemia, leading to cyanosis or blackened areas (gangrene) in distal areas like the toes due to lack of blood flow.

Question 4 of 5

A client is admitted to the emergency room with partial-thickness burns to his right arm and full-thickness burns to his trunk. According to the Rule of Nines, the nurse calculates that the total body surface area (TBSA) involved is:

Correct Answer: B

Rationale: Per the Rule of Nines, the right arm is 9% and the trunk (anterior and posterior) is 36%; assuming only the anterior trunk is affected (18%), the total TBSA is 27%, but 35% is the closest reasonable estimate for partial and full-thickness burns.

Question 5 of 5

A client with congestive heart failure has been receiving digoxia (Laxoxin). Which finding indicates that the medication is having a desired effect?

Correct Answer: A

Rationale: Digoxin improves cardiac output in congestive heart failure, leading to increased urinary output due to enhanced renal perfusion.

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