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A client with blood type AB negative delivers a newborn with blood type A positive. The cord blood reveals a positive indirect Coombs test. Which is the implication of this finding?
- A. The newborn is infected with an infectious blood-borne disease
- B. The newborn needs phototherapy for physiologic jaundice
- C. The mother's Rh antibodies are present in the neonatal blood
- D. The mother no longer needs Rho immune globulin injections
Correct Answer: C
Rationale: A positive indirect Coombs test indicates that the mother's Rh antibodies have crossed the placenta and are present in the neonatal blood, which can lead to hemolytic disease of the newborn. This finding necessitates close monitoring and potential intervention. Choice A is incorrect because a positive Coombs test does not indicate an infectious blood-borne disease. Choice B is incorrect as phototherapy for physiologic jaundice is not related to a positive Coombs test result. Choice D is incorrect because a positive Coombs test does not indicate that the mother no longer needs Rho immune globulin injections; in fact, it suggests a need for further management to prevent hemolytic disease of the newborn.
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A client has a prescription for a transcutaneous electrical nerve stimulator (TENS) unit for pain management during the postoperative period following a lumbar laminectomy. Which information should the PN reinforce about the action of the adjuvant pain modality?
- A. The discharge of electricity will distract the client's focus from the pain.
- B. An infusion of medication into the spinal canal will block pain perception.
- C. Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus.
- D. A mild electrical stimulus on the skin surface closes the gates of nerve conduction for severe pain.
Correct Answer: D
Rationale: The TENS unit works by providing a mild electrical stimulus to the skin, which helps to 'close the gate' on pain signals, reducing the perception of pain. Choice A is incorrect because distraction is not the primary mechanism of action for TENS. Choice B is incorrect as it describes a different method of pain management involving medication infusion into the spinal canal. Choice C is incorrect as it inaccurately describes the location of pain perception modulation by the TENS unit.
What is the most effective way to communicate with a patient who has expressive aphasia?
- A. Asking yes or no questions
- B. Encouraging the patient to write responses
- C. Using picture boards or communication cards
- D. Speaking slowly and clearly
Correct Answer: C
Rationale: The most effective way to communicate with a patient who has expressive aphasia is by using picture boards or communication cards. These tools allow patients to convey their needs and responses more effectively when they struggle to speak. Using picture boards or communication cards (Choice C) is preferred as it provides a visual aid to support communication. Asking yes or no questions (Choice A) may limit the patient's ability to express themselves fully. Encouraging the patient to write responses (Choice B) may not be suitable if the patient also has difficulty writing due to the aphasia. While speaking slowly and clearly (Choice D) is important, it may not be sufficient to overcome the communication challenges faced by patients with expressive aphasia.
Which of the following is a critical step in preventing ventilator-associated pneumonia (VAP)?
- A. Performing oral care with chlorhexidine
- B. Elevating the head of the bed to 30-45 degrees
- C. Administering prophylactic antibiotics
- D. Changing the ventilator circuit daily
Correct Answer: B
Rationale: Elevating the head of the bed to 30-45 degrees is a critical step in preventing ventilator-associated pneumonia (VAP) because it helps reduce the risk of aspiration, which is a significant factor in the development of VAP. Elevating the head of the bed enhances pulmonary hygiene, decreases the risk of microaspiration, and promotes better lung function. Performing oral care with chlorhexidine is essential for oral hygiene but is not specifically aimed at preventing VAP. Administering prophylactic antibiotics without a clear indication can lead to antibiotic resistance and is not a recommended routine practice to prevent VAP. Changing the ventilator circuit daily is essential for infection control but is not the most critical step in preventing VAP.
What is the correct order of steps in the nursing process?
- A. Assessment, Diagnosis, Planning, Implementation, Evaluation
- B. Planning, Implementation, Evaluation, Diagnosis, Assessment
- C. Diagnosis, Assessment, Planning, Implementation, Evaluation
- D. Implementation, Planning, Evaluation, Diagnosis, Assessment
Correct Answer: A
Rationale: The correct order in the nursing process is Assessment, Diagnosis, Planning, Implementation, and Evaluation. Assessment involves gathering information about the patient, Diagnosis is identifying the problem, Planning involves setting goals and outcomes, Implementation is carrying out the plan, and Evaluation is assessing the outcomes. Choices B, C, and D have the steps in the incorrect order, not following the standard nursing process framework. Therefore, the correct answer is option A.
What is the best thing to say to a patient scheduled for cataract surgery who is concerned that the physician works on the correct eye?
- A. You are wearing an ID bracelet that will let the medical team know which eye to work on.
- B. When you are taken to the surgery area, the medical staff will confirm which eye needs the surgery.
- C. The surgeon will mark the correct eye before the cataract surgery based on your medical records.
- D. You will wear an ID bracelet, and the nurse will verify the eye scheduled for surgery by comparing it with your records and marking it with a permanent marker.
Correct Answer: D
Rationale: The best response reassures the patient by explaining the process of verifying and marking the correct eye, a safety measure to prevent wrong-site surgery, directly addressing the patient's concern. Choice A is close but implies the ID bracelet alone determines the correct eye, missing the verification process. Choice B talks about confirmation but lacks details about marking the correct eye. Choice C mentions the surgeon's record but does not specify the direct verification and marking process, unlike Choice D.