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Questions 164

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Question 1 of 5

While reviewing the chart of an elderly client, the nurse notes that the last recorded temperature for the preceding shift was 104°. There is no documented intervention. The nurse should:

Correct Answer: D

Rationale: Retaking the temperature verifies the current status, as the fever may have resolved. Checking orders or asking the client assumes the fever persists, and calling the nurse is impractical.

Question 2 of 5

While caring for a client in skeletal traction, which tasks can the nurse assign to experienced unlicensed assistive personnel to help prevent immobility hazards? Select all that apply.

Correct Answer: A,D,E

Rationale: Assisting with range of motion, reapplying compression devices, and reminding about spirometry are within UAP scope and prevent immobility issues. Assessing extremities and logrolling require nursing judgment.

Question 3 of 5

A client has sustained second- and third-degree burns over her entire left arm and posterior trunk. Using the Rule of Nines, which percentage of the client's body is burned?

Correct Answer: C

Rationale: Per the Rule of Nines, one arm is 9% and the posterior trunk is 18%, totaling 27% body surface area burned.

Question 4 of 5

The orthopedic health care provider instructs a client with a fractured right femur, who has been non-weight bearing for the past 5 weeks, to progress to full-weight bearing on the right leg. Which advanced crutch gait that most closely resembles normal walking should the nurse reinforce when teaching the client?

Correct Answer: A

Rationale: The 2-point gait mimics normal walking, alternating crutch and opposite leg, suitable for full-weight bearing. 3-point is for non-weight bearing, 4-point is slower, and 5-point does not exist.

Question 5 of 5

A woman comes into the labor suite stating that her water has broken and she is in labor. Which symptoms point to the possible presence of placenta previa?

Correct Answer: C

Rationale: Placenta previa typically presents with bright red, painless vaginal bleeding due to the placenta covering the cervix, distinguishing it from abruptio placentae or other conditions.

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