Correct Answer: D

Rationale: Administering a local anesthetic at the injection site can help reduce pain during immunizations in infants. Options A, B, and C are incorrect. Administering the immunization in the deltoid muscle may not provide pain relief. Applying a cold compress or pressure to the injection site is not as effective as using a local anesthetic to reduce pain.

Correct Answer: C

Rationale: Taking insulin at the same time each day helps maintain stable blood glucose levels and prevent complications.

Correct Answer: D

Rationale: In this scenario, the nurse should anticipate initiating continuous bladder irrigation. Dark yellow urine output at a rate of 25 ml/hr following abdominal surgery may indicate urinary stasis or obstruction, which could lead to complications like urinary retention. Continuous bladder irrigation helps prevent catheter obstruction and manage urinary retention by ensuring patency and promoting urine flow. Clamping the catheter (Choice A) could lead to urinary stasis and should be avoided. Administering a fluid bolus (Choice B) is not indicated solely based on the urine color and output described. Obtaining a urine specimen for culture and sensitivity (Choice C) may be necessary for assessing infection but does not directly address the issue of urinary stasis or obstruction.

Correct Answer: D

Rationale: The correct answer is D, 'Undermining.' Undermining occurs when the tissue under the wound edges erodes, indicating poor healing progress. This finding should be reported to the provider as it suggests delayed wound healing and may require intervention. Choice A, 'Eschar,' is a thick, hard, black/brown necrotic tissue that forms over a wound. While it indicates a non-healing wound, it is not as concerning as undermining. Choice B, 'Slough,' is a soft, moist, yellow/white tissue that is also a sign of necrosis. While the presence of slough indicates the need for wound cleaning and debridement, it is not as critical to report as undermining. Choice C, 'Granulation tissue,' is new tissue that forms during wound healing and is a positive sign. The presence of granulation tissue indicates that the wound is progressing through the healing stages and is not a finding that requires immediate reporting to the provider.

Correct Answer: A

Rationale: The correct answer is to verify the client's blood type with the provider's prescription. This is crucial to prevent an adverse transfusion reaction due to incompatibility. Ensuring the blood type matches before starting the transfusion is a standard safety practice. Option B, ensuring client consent, is important but not directly related to preventing a transfusion reaction. Option C, administering a diuretic, is unnecessary and can be harmful in this context. Option D, checking the client's temperature, is important for general assessment but not specifically focused on preventing a transfusion reaction.