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Question 1 of 5

The nurse is collecting data from a client who had a transurethral resection of the prostate 10 hours ago and is receiving continuous bladder irrigation. Which of the following findings would require follow-up?

Correct Answer: D

Rationale: A 200 mL discrepancy between irrigation input and output suggests possible catheter obstruction or absorption, requiring follow-up. Normal vitals , spasm relief , and light pink urine are expected post-TURP.

Question 2 of 5

A client has been admitted with a fractured femur and has been placed in skeletal traction. Which of the following nursing interventions should receive priority?

Correct Answer: B

Rationale: The most important activity for the nurse is to assess neurovascular status. Compartment syndrome is a serious complication of fractures. Prompt recognition of this neurovascular problem and early intervention may prevent permanent limb damage.

Question 3 of 5

The perinatal nurse is reviewing telephone messages from clients. The nurse should first telephone the client who is at

Correct Answer: D

Rationale: Ibuprofen at 32 weeks gestation is concerning due to risks of premature ductus arteriosus closure and oligohydramnios, requiring immediate follow-up. Mild diarrhea and dark urine with metronidazole are less urgent, and acetaminophen is safe.

Question 4 of 5

A 67 year-old client with non-insulin dependent diabetes should be instructed to contact the out-patient clinic immediately if the following findings are present

Correct Answer: B

Rationale: An open, reddened wound on the heel. When signs of trauma and/or infection occur in their feet, elderly clients who have diabetes and/or vascular disease should seek health care quickly and continue treatment until the problem is resolved. Without treatment, serious infection, gangrene, limb loss, and death may result.

Question 5 of 5

A woman brings her 6-month-old daughter to a clinic for a checkup and immunizations. The mother tells the nurse that her infant is cranky, has a bad cold, and has not eaten well the last days. She asks if the baby will still be able to get her shots. The child's temperature is 100.8°F. How should the nurse respond?

Correct Answer: B

Rationale: Mild fever and illness contraindicate vaccinations due to potential reduced immune response and difficulty distinguishing vaccine reactions from illness symptoms.

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