The nurse is caring for an 88-year-old client admitted to the orthopedic floor with the diagnosis of fractured pelvis. Which intervention should the nurse implement first?

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Question 1 of 5

The nurse is caring for an 88-year-old client admitted to the orthopedic floor with the diagnosis of fractured pelvis. Which intervention should the nurse implement first?

Correct Answer: C

Rationale: Assessing bowel sounds first evaluates gastrointestinal function, which can be affected by a pelvic fracture and is a priority before invasive interventions.

Question 2 of 5

The nurse is evaluating a client in skeletal traction. When evaluating the pin sites, the nurse would be most concerned with which finding?

Correct Answer: C

Rationale: Thick, yellow drainage indicates infection, a serious concern requiring intervention.

Question 3 of 5

Which technique would be most appropriate for the nurse to implement when assessing a four (4)-year-old client in acute pain?

Correct Answer: C

Rationale: The FACES pain scale, where the child points to a face, is age-appropriate for a 4-year-old, who may not understand numerical scales or complex words.

Question 4 of 5

The client is complaining of ringing in the ears. Which data are most appropriate for the nurse to document in the client's chart?

Correct Answer: C

Rationale: Tinnitus is the medical term for ringing in the ears, making it the most precise documentation for this complaint.

Question 5 of 5

Which signs/symptoms should the nurse expect to find when assessing the client with an acoustic neuroma?

Correct Answer: D

Rationale: Acoustic neuromas typically present with unilateral hearing loss and tinnitus.

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