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A client who underwent cardiac surgery 2 days ago is recovering well. His wife, who is assisting with his care, says, 'He is doing too much. I told him to let me help, but he won't let me.' The nurse says to the wife, 'It sounds like you need to feel you can be more helpful to him.' In order to make her nonverbal behavior complement her words, the nurse should:
- A. Direct the eyes at the client.
- B. Direct the body and eyes at the wife and client.
- C. Avoid direct eye contact with the client and wife.
- D. Shift the eyes back and forth between the client and wife.
Correct Answer: B
Rationale: Directing body and eyes to both the wife and client shows engagement and inclusivity, complementing the empathetic verbal response.
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To protect a client who has received tissue plasminogen activator (t-PA, or Activase) therapy, the nurse should:
- A. Use the radial artery to obtain blood gas samples.
- B. Maintain arterial pressure for 10 seconds.
- C. Administer I.M. injections.
- D. Encourage physical activity.
Correct Answer: B
Rationale: Maintaining pressure on arterial puncture sites for 10 seconds minimizes bleeding risk, critical after t-PA due to its thrombolytic effects.
What are the nursing implications associated with administering blood and blood products to a client who has a blood type of B negative?
- A. The nurse must be knowledgeable about the fact that this client has A and B agglutinins and lacks the Rh factor
- B. The nurse must be knowledgeable about the fact that this client has B and O agglutinins and lacks the Rh factor
- C. The nurse must be knowledgeable about the fact that this client has B agglutinins and lacks the Rh factor
- D. The nurse must be knowledgeable about the fact that this client has A agglutinins and lacks the Rh factor
Correct Answer: C
Rationale: B negative blood type has anti-A agglutinins (antibodies against A antigen) and lacks the Rh factor, requiring careful matching to avoid transfusion reactions.
The nurse is assessing a neonate born to a diabetic mother. Which of the following findings should the nurse expect to see in the infant?
- A. Hypertonia
- B. Hyperactivity
- C. Large size
- D. Scaly skin
Correct Answer: C
Rationale: Neonates born to diabetic mothers are often macrosomic (large size) due to maternal hyperglycemia. Hypertonia, hyperactivity, and scaly skin are not typical findings.
The nurse coordinates with the laboratory staff to have the gentamicin trough serum level drawn. At what time should the blood be drawn in relation to the administration of the I.V. dose of gentamicin sulfate [Garamycin]?
- A. 2 hours before the administration of the next I.V. dose.
- B. 3 hours before the administration of the next I.V. dose.
- C. 4 hours before the administration of the next I.V. dose.
- D. Just before the administration of the next I.V. dose.
Correct Answer: D
Rationale: The trough level, which measures the lowest drug concentration, is drawn just before the next dose to ensure the drug is within a therapeutic range and to avoid toxicity.
The nurse is assessing a neonate at 5 minutes after birth. The nurse records the Apgar score based on the findings in the chart below. The nurse compares these findings to the Apgar score obtained at birth, as determined by the findings in the chart below. What should the nurse do next?
- A. Notify the neonatologist on call.
- B. Continue to assess the neonate.
- C. Apply an oxygen mask.
- D. Rub the neonate's extremities.
Correct Answer: B
Rationale: Without specific Apgar score data, the standard action is to continue assessing the neonate, as Apgar scores at 5 minutes guide ongoing monitoring unless critical findings are present.