Nokea
A primigravida with a blood type A negative is at 28 weeks' gestation. Today her physician has ordered a RhoGAM injection. Which statement by the client demonstrates that more teaching is needed related to this therapy?
- A. I'm getting this shot so that my baby won't develop antibodies against my blood, right?'
- B. I understand that if my baby is Rh positive I'll be getting another one of these injections.'
- C. This shot should help to protect me in future pregnancies if this baby is Rh positive, like my husband.'
- D. This shot will prevent me from becoming sensitized to Rh-positive blood.'
Correct Answer: A
Rationale: RhoGAM is given to Rh-negative mothers to prevent the maternal Rh immune response to fetal Rh-positive antigens. If the infant is Rh positive, the mother will receive another dose postdelivery to prevent maternal sensitization. Prevention of maternal sensitization will protect future pregnancies because the mother's blood will be free of antibodies against her fetus. RhoGAM prevents maternal sensitization to Rh-positive blood.
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A client with a history of a burn injury is receiving Hydrotherapy. The nurse should:
- A. Use hot water for cleaning
- B. Apply petroleum-based products
- C. Monitor the water temperature
- D. Cover the wounds with plastic wrap
Correct Answer: C
Rationale: Monitoring water temperature during hydrotherapy prevents further burn injury, ensuring it’s lukewarm. Hot water, petroleum products, and plastic wrap are contraindicated.
A 2-year-old boy is in the hospital outpatient department for observation after falling out of his crib and hitting his head. The nurse calls the physician to report:
- A. Evidence of perineal irritation
- B. Pulse fell from 102 to 96
- C. Pulse increased from 96 to 102
- D. Temperature rose to 102_F rectally
Correct Answer: D
Rationale: Perineal irritation needs to be addressed, but it is probably not necessary to call the physician. This fall in pulse rate remains within normal limits and is probably insignificant. It is important to monitor for continued change. This rise in pulse rate is probably not significant, but it is important to monitor for continued change. This temperature is above normal limits and needs medical investigation. It may or may not be related to the head injury.
A 25-year-old lawyer who is married with three young children works long hours in an effort to become a partner in the law firm. Following a recent hospitalization for a bleeding ulcer, he was referred for therapy to treat this psychophysiological disorder. On meeting with the therapist, he informed him or her that he was a busy man and did not have much time for this 'psych stuff.' When guiding the client to ventilate his feelings, the therapist can expect him to express feelings of:
- A. Guilt
- B. Shame
- C. Despair
- D. Anger
Correct Answer: D
Rationale: Repressed anger is associated with psychophysiological disorders like a bleeding ulcer, as stress and unexpressed emotions contribute to physical symptoms.
The nurse is assessing a trauma client in the emergency room when she notes a penetrating abdominal wound with exposed viscera. The nurse should:
- A. Apply a clean dressing to protect the wound.
- B. Cover the exposed viscera with a sterile saline gauze.
- C. Gently replace the abdominal contents.
- D. Cover the area with a petroleum gauze.
Correct Answer: B
Rationale: Exposed viscera should be covered with sterile saline-soaked gauze to keep them moist and prevent infection until surgical repair. Replacing contents or using non-sterile/petroleum dressings is unsafe.
A client has received digoxin 0.25 mg po daily for 2 weeks. Which of the following digoxin levels indicates toxicity?
- A. 0.5 ng/mL
- B. 1.0 ng/mL
- C. 2.0 ng/mL
- D. 3.0 ng/mL
Correct Answer: D
Rationale: Digoxin's therapeutic level is 0.8-2.0 ng/mL. Digoxin's toxic level is >2.0 ng/mL.