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Questions 163

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Question 1 of 5

The nurse observes a nursing assistant caring for an 86-year-old woman who had an open reduction/internal fixation for a fractured femur two days ago. Which action by the nursing assistant needs correction by the nurse?

Correct Answer: B

Rationale: Full weight-bearing two days post-femur fixation is inappropriate, risking hardware failure; partial or non-weight-bearing is typical. Abductor pillows, commodes, and self-bathing are appropriate.

Question 2 of 5

The physician has ordered a sterile urine specimen to be collected from a client who has a Foley catheter. To obtain a sterile urine specimen, the nurse should:

Correct Answer: D

Rationale: Withdrawing from the catheter port with a syringe ensures a sterile specimen. Other methods risk contamination.

Question 3 of 5

The nurse working on a medical-surgical unit receives change-of-shift report on several clients. Which client should the nurse see first?

Correct Answer: D

Rationale: A fever of 100.9 F post-arteriovenous graft suggests possible infection, requiring immediate assessment. Cramping and minor bleeding are expected post-polypectomy, urinary hesitancy is common post-hernia repair, and straining is less urgent.

Question 4 of 5

The nurse is reviewing the medical record of a 4-year-old client with failure to thrive. Which of the following risk factors likely contribute to the client's condition? Select all that apply.

Correct Answer: B,C,E

Rationale: FTT risk factors include parental incarceration causing family stress, a history of anorexia nervosa affecting feeding practices, and food insecurity . Being the youngest or a working parent are not direct risks.

Question 5 of 5

A client with cancer received platelet infusions 24 hours ago. Which of the following assessment findings would indicate the most therapeutic effect from the transfusions?

Correct Answer: D

Rationale: Platelets deal with the clotting of blood. Lack of platelets can cause bleeding. Answers A, B, and C do not directly relate to platelets, so they are incorrect.

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