The unlicensed assistive personnel (UAP) reports a sudden increase in temperature to 101 degrees Fahrenheit for a post surgical client. The nurse checks on the client's condition and observes a cup of steaming coffee at the bedside. What instructions are appropriate to give to the UAP?

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Question 1 of 5

The unlicensed assistive personnel (UAP) reports a sudden increase in temperature to 101 degrees Fahrenheit for a post surgical client. The nurse checks on the client's condition and observes a cup of steaming coffee at the bedside. What instructions are appropriate to give to the UAP?

Correct Answer: B

Rationale: Recheck temperature 15 minutes after removing hot liquids' is appropriate. Coffee likely raised oral temp; rechecking ensures accuracy. Fluids (A, C) or charting miss causation. B aligns with protocol, making it correct.

Question 2 of 5

A client has been tentatively diagnosed with Graves' disease (hyperthyroidism). Which of these findings noted on the initial nursing assessment requires quick intervention by the nurse?

Correct Answer: C

Rationale: Exophthalmos requires quick intervention in Graves'. Bulging eyes signal thyroid orbitopathy, needing urgent referral to prevent vision loss. Weight loss , restlessness , and irritability are managed less acutely. C prioritizes complication, making it critical.

Question 3 of 5

The nurse is assigned to care for a client who had a myocardial infarction (MI) 2 days ago. The client has many questions about this condition. What area is a priority for the nurse to discuss at this time?

Correct Answer: D

Rationale: Activity and rest guidelines are priority 2 days post-MI. They prevent strain, aiding recovery, per acute phase needs. Daily needs , rehab , and meds/diet follow. D ensures safety, making it key.

Question 4 of 5

The nurse is performing a physical assessment on a toddler. Which of the following actions should be the first?

Correct Answer: B

Rationale: Using minimal physical contact is first for a toddler. It builds trust, reducing fear, per development. Traumatic procedures , head-to-toe , or explanation follow. B ensures cooperation, making it initial.

Question 5 of 5

The nurse is assessing a client with a suspected bowel obstruction. Which finding should the nurse report immediately to the health care provider?

Correct Answer: B

Rationale: High-pitched bowel sounds need immediate reporting in suspected bowel obstruction. They indicate hyperperistalsis from blockage, risking perforation, per pathophysiology. Nausea , mild pain , and 12-hour stool absence are less urgent. B signals progression, making it critical.

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