Final Exam Practice
,The nurse is caring for a client with a pelvic fracture.
Which is the nurse’s priority action to prevent
complications?
a. Monitor and trend temperature
b. Insert a Foley catheter and drain to gravity
c. Monitor and trend blood pressure
d. Turn the client every 2 hours
,Correct Answer: C
Rationale: The greatest risk with a pelvic fracture is
blood loss. In order to determine if the client is
hypovolemic, the nurse would need to monitor the
blood pressure frequently. Temperature is also
important, but it would need to be done at least once
every 8 hours, not daily. The client may not need a
Foley and this would not prevent complications related
to hypovolemia. The client would need to be turned
every 2 hours, but this doesn’t take priority over
assessing for blood loss.
, Paramedics transport a client to the emergency department.
They report “the client fell from a 16-foot ladder, has a large
contusion on his left chest, a hematoma in the left temporal
area, a compound fracture of the right femur, and is
unresponsive.” The client is intubated and maintains an
oxygen saturation of 92% with a manual resuscitation bag.
Which action by the nurse has the highest priority?
a. Assessing the right leg
b. Assessing the level of consciousness
c. Assessing the pupils
d. Placing the client in Trendelenburg's position
,The nurse is caring for a client with a pelvic fracture.
Which is the nurse’s priority action to prevent
complications?
a. Monitor and trend temperature
b. Insert a Foley catheter and drain to gravity
c. Monitor and trend blood pressure
d. Turn the client every 2 hours
,Correct Answer: C
Rationale: The greatest risk with a pelvic fracture is
blood loss. In order to determine if the client is
hypovolemic, the nurse would need to monitor the
blood pressure frequently. Temperature is also
important, but it would need to be done at least once
every 8 hours, not daily. The client may not need a
Foley and this would not prevent complications related
to hypovolemia. The client would need to be turned
every 2 hours, but this doesn’t take priority over
assessing for blood loss.
, Paramedics transport a client to the emergency department.
They report “the client fell from a 16-foot ladder, has a large
contusion on his left chest, a hematoma in the left temporal
area, a compound fracture of the right femur, and is
unresponsive.” The client is intubated and maintains an
oxygen saturation of 92% with a manual resuscitation bag.
Which action by the nurse has the highest priority?
a. Assessing the right leg
b. Assessing the level of consciousness
c. Assessing the pupils
d. Placing the client in Trendelenburg's position
