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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?
- A. blood pressure of 114/70 mm Hg and heart rate of 66/min
- B. reports relief of bladder spasms after administration of oxybutynin
- C. light pink urine is noted in the catheter tubing and urinary drainage bag
- D. bladder irrigation input of 3000 mL and urine output of 2800 mL over the past 4 hours
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.
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The health care provider has told a client to take over-the-counter supplemental calcium carbonate 1000 mg/day for treatment of osteoporosis. Which instruction should the clinic nurse reinforce with the client?
- A. Monthly calcium levels will need to be drawn
- B. Stop vitamin D supplements when taking calcium
- C. Take calcium at bedtime
- D. Take calcium in divided doses with food
Correct Answer: D
Rationale: Taking calcium carbonate in divided doses with food enhances absorption and reduces GI upset. Monthly calcium levels are unnecessary, vitamin D should continue, and bedtime dosing is less effective.
A client is in suspected shock state from major trauma. Which of the following parameters indicate the adequacy of peripheral perfusion? Select all that apply.
- A. Apical pulse
- B. Capillary refill time
- C. Lung sounds
- D. Pupillary response
- E. Skin color and temperature
Correct Answer: B,E
Rationale: Capillary refill time and skin color/temperature directly assess peripheral perfusion in shock. Apical pulse , lung sounds , and pupillary response evaluate other aspects.
Which of the following tasks can the practical nurse (PN) safely assign to an experienced unlicensed assistive personnel (UAP)? Select all that apply.
- A. Ambulate an oxygen-dependent client to the bathroom
- B. Check pulse oximetry for a client with respiratory rate 12/min
- C. Instruct a client with pneumonia on usage of the incentive spirometer
- D. Provide oral hygiene to a client with chronic obstructive pulmonary disease (COPD)
- E. Turn and reposition a client with pneumonia
Correct Answer: A,B,D,E
Rationale: UAP can ambulate stable clients , check pulse oximetry , provide oral hygiene , and reposition clients . Instructing on incentive spirometry requires nursing judgment and is not delegable.
The nurse in the outpatient care facility is caring for a client who is blind. Which of the following actions should the nurse take?
- A. Offer the client's service dog food and water.
- B. Teach the client how to ambulate with a stability cane.
- C. Touch the client's shoulder before speaking to the client.
- D. Walk slightly ahead of the client with the client holding the nurse's elbow
Correct Answer: D
Rationale: Walking slightly ahead with the client holding the nurse's elbow is the standard technique for guiding a blind person safely. Offering food to a service dog is inappropriate, teaching cane use assumes need, and touching without warning may startle.
The client tells the nurse she is having trouble falling asleep. What initial nursing action is least appropriate?
- A. Asking the physician for a sleeping medication
- B. Offering the client a back rub
- C. Asking the client if she is concerned about something
- D. Repositioning the client
Correct Answer: A
Rationale: Requesting sleeping medication is premature and least appropriate without exploring non-pharmacologic interventions like back rubs, addressing concerns, or repositioning, which promote sleep naturally.