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A nurse is reviewing urinary laboratory results.Which finding will cause the nurse to follow up?
- A. Protein level of 2 mg/100 mL
- B. Urine output of 80 mL/hr
- C. Specific gravity of 1.036
- D. pH of 6.4
Correct Answer: A
Rationale: The correct answer is A because a protein level of 2 mg/100 mL in urine indicates proteinuria, which can be a sign of kidney dysfunction or other underlying health issues. The nurse should follow up to assess further for possible kidney disease or other conditions.
Choice B is not a cause for concern as a urine output of 80 mL/hr is within the normal range.
Choice C indicates concentrated urine, which may be due to dehydration but does not necessarily require immediate follow-up.
Choice D is within the normal range for urine pH and does not typically warrant immediate follow-up.
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Examination of a newborn in the birth room reveals bilateral cataracts. Which disease process in the maternal history would likely cause this abnormality?
- A. Rubella
- B. Cytomegalovirus (CMV)
- C. Syphilis
- D. HIV
Correct Answer: A
Rationale: The correct answer is A: Rubella. Rubella infection during pregnancy can lead to congenital rubella syndrome, which includes bilateral cataracts as a characteristic feature. Rubella virus can cross the placenta and affect the developing fetus. Cytomegalovirus (CMV) can also cause congenital cataracts, but rubella is more commonly associated with this abnormality. Syphilis can cause other congenital abnormalities but not bilateral cataracts. HIV does not typically lead to bilateral cataracts in newborns.
When teaching patients about the risk factors of cervical cancer, what would the nurse identify as the most important risk factor?
- A. Late childbearing
- B. Human papillomavirus (HPV)
- C. Postmenopausal bleeding
- D. Tobacco use
Correct Answer: B
Rationale: The correct answer is B: Human papillomavirus (HPV). HPV is the most important risk factor for cervical cancer as it is responsible for almost all cases. Step 1: HPV infection can lead to changes in cervical cells, increasing the risk of cancer. Step 2: Early detection and vaccination against HPV can prevent cervical cancer. Step 3: Other factors like late childbearing, postmenopausal bleeding, and tobacco use may be associated with increased risk but are not as directly linked to cervical cancer development.
A nurse is caring for a patient who just underwentan intravenous pyelography that revealed a renal calculus obstructing the left ureter. What is the nurse’sfirstpriorityin caring for this patient?
- A. Turn the patient on the right side to alleviate pressure on the left kidney.
- B. Encourage the patient to increase fluid intake to flush the obstruction.
- C. Monitor the patient for fever, rash, and difficulty breathing.
- D. Administer narcotic medications to the patient for pain.
Correct Answer: C
Rationale: The correct answer is C: Monitor the patient for fever, rash, and difficulty breathing. The rationale is as follows:
1. Renal calculus obstruction can lead to complications such as infection, so monitoring for fever is crucial.
2. Rash can indicate an allergic reaction to the contrast dye used in the procedure.
3. Difficulty breathing may signal a severe reaction or complications.
Summary:
A: Turning the patient on the right side does not directly address the urgent need to monitor for potential complications.
B: While fluid intake is important, it is not the immediate priority when the patient is at risk of developing complications.
D: Administering narcotic medications may be necessary for pain relief but does not address the potential emergent issues related to the obstruction.
A nurse would identify that a colleague needs additional instruction on standard precautions when the colleague exhibits which of the following behaviors?
- A. The nurse wears face protection, gloves, and a gown when irrigating a wound.
- B. The nurse washes the hands with a waterless antiseptic agent after removing a pair of soiled gloves.
- C. The nurse puts on a second pair of gloves over soiled gloves while performing a bloody procedure.
- D. The nurse places a used needle and syringe in the puncture-resistant container without capping the needle.
Correct Answer: C
Rationale: The correct answer is C because putting on a second pair of gloves over soiled gloves during a procedure violates standard precautions by increasing contamination risk. Here's the rationale:
1. Standard precautions require removing soiled gloves before putting on new ones to prevent cross-contamination.
2. Wearing multiple gloves increases the risk of tearing and exposure to pathogens.
3. This behavior shows a lack of understanding of proper infection control practices.
Summary of other choices:
A: Wearing face protection, gloves, and a gown when irrigating a wound is a correct practice.
B: Washing hands with waterless antiseptic after removing soiled gloves is correct.
D: Placing a used needle and syringe in a puncture-resistant container without capping the needle is incorrect, but not as severe as choice C.
As the triage nurse in the emergency room, you are reviewing results for the high-risk obstetric patient who is in labor because of traumatic injury experienced as a result of a motor vehicle accident (MVA). You note that the Kleihauer–Betke test is positive. Based on this information, you anticipate that
- A. immediate birth is required.
- B. the patient should be transferred to the critical care unit for closer observation.
- C. RhoGAM should be administered.
- D. a tetanus shot should be administered.
Correct Answer: A
Rationale: The correct answer is A: immediate birth is required. The Kleihauer–Betke test is used to detect fetal-maternal hemorrhage in situations where there is a risk of fetal blood entering the maternal circulation, such as trauma during pregnancy. A positive result indicates a significant fetal-maternal hemorrhage, which can lead to Rh incompatibility and severe fetal anemia. Immediate birth is required to prevent complications and ensure the safety of both the mother and the baby.
Choice B is incorrect as transferring the patient to the critical care unit does not address the underlying issue of fetal-maternal hemorrhage. Choice C is incorrect as RhoGAM is typically administered to prevent Rh sensitization in Rh-negative mothers carrying Rh-positive babies, which is not the primary concern in this scenario. Choice D is incorrect as a tetanus shot is not directly related to the positive Kleihauer–Betke test result indicating fetal-maternal hemorrhage.