Nokea
A client with $B$ positive blood is scheduled for a transfusion of whole blood. Which finding requires nursing intervention?
- A. The available blood has been banked for 2 weeks.
- B. The blood available for transfusion is Rh negative.
- C. The client has a peripheral IV of D5 $1 / 2$ normal saline.
- D. The blood available for transfusion is type 0 positive.
Correct Answer: B
Rationale: Transfusing Rh-negative blood to an Rh-positive client can cause incompatibility reactions, requiring intervention to ensure Rh compatibility.
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After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions would be MOST appropriate?
- A. Irrigate the nasogastric tube with distilled water.
- B. Aspirate the gastric contents with a syringe.
- C. Administer an antiemetic medicine.
- D. Insert a new nasogastric tube.
Correct Answer: B
Rationale: to confirm placement, nurse should aspirate and test the pH of the aspirate, results should be 0-4
The nurse is caring for a client who is postoperative day 1 following a laparoscopic appendectomy. The client reports shoulder pain. Which of the following actions should the nurse take?
- A. Administer an analgesic as ordered.
- B. Notify the physician immediately.
- C. Explain that this is referred pain from residual gas.
- D. Place the client in a prone position.
Correct Answer: C
Rationale: shoulder pain after laparoscopic surgery is often due to referred pain from residual carbon dioxide used during the procedure
After the physician performs an amniotomy, the nurse's first action should be to assess the:
- A. Degree of cervical dilation
- B. Fetal heart tones
- C. Client's vital signs
- D. Client's level of discomfort
Correct Answer: B
Rationale: Post-amniotomy, assessing fetal heart tones is critical to detect potential cord prolapse or distress.
The nurse is administering terbutaline (Brethine) to a client in labor. Prior to administration of the medication, the nurse assesses the client’s pulse to be 144. The nurse’s priority action should be to
- A. withhold the medication.
- B. decrease the dose by half.
- C. administer the medication.
- D. wait 15 minutes, then recheck the rate.
Correct Answer: A
Rationale: maternal tachycardia is a side effect of Brethine; other maternal side effects include nervousness, tremors, headache, and possible pulmonary edema; fetal side effects include tachycardia and hypoglycemia; Brethine is usually preferred over ritodrine (Yutopar) because it has minimal effects on blood pressure
All of the following are risk factors for sudden infant death syndrome (SIDS) EXCEPT
- A. low birth weight.
- B. placing the child on his back to sleep.
- C. young maternal age.
- D. maternal smoking during pregnancy.
Correct Answer: B
Rationale: Placing an infant on their back to sleep reduces SIDS risk. Low birth weight, young maternal age, and maternal smoking are known risk factors.