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Questions 163

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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 72-year-old woman is being treated for pneumonia. Physician's orders include an antibiotic, oxygen PRN for O2 saturation less than 90, and pulse oximetry every 4 hours. The nurse obtains a pulse oximetry reading of 82% on room air. What is the best action for the nurse to take?

Correct Answer: C

Rationale: An O2 saturation of 82% requires immediate supplemental oxygen per orders to correct hypoxia, the priority action.

Question 3 of 5

It is the first day on the job for the newly hired unlicensed assistive personnel (UAP). Which of these illustrate appropriate assignment instructions for the licensed practical nurse (LPN) to give the UAP? Select all that apply.

Correct Answer: A,C,D

Rationale: Appropriate UAP tasks include elevating a leg , observing urine appearance , and reporting food intake . Measuring for stockings and verifying restraints require nursing judgment.

Question 4 of 5

The clinic nurse is caring for several clients during well-child visits. The nurse should recognize which client as being the most at risk for anemia?

Correct Answer: C

Rationale: A preterm infant bottle-fed with breastmilk is most at risk for anemia due to preterm infants' lower iron stores and breastmilk's low iron content. Term breastfed infants (A,
D) have adequate stores initially, and iron-fortified formula prevents anemia.

Question 5 of 5

The nurse in the emergency department is caring for a client who was involved in a motor vehicle collision. Which of the following diagnostic test results would best determine the client's oxygenation and ventilation status?

Correct Answer: B

Rationale: Arterial blood gas provides the most accurate assessment of oxygenation (PaO2) and ventilation (PaCO2) post-collision. Peak flow assesses asthma, pulse oximetry measures oxygen saturation only, and CT evaluates structure.

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