Nokea
An Rh-negative woman with previous sensitization has delivered an Rh-positive fetus. Which of the following nursing actions should be included in the client's care plan?
- A. emotional support to help the family deal with feelings of guilt about the infant's condition
- B. administration of MICRhoGam to the woman within 72 hours of delivery
- C. administration of Rh-immune globulin to the newborn within 1 hour of delivery
- D. lab analysis of maternal Direct Coombs' test
Correct Answer: A
Rationale: Sensitization means the mother has antibodies against Rh-positive blood, risking hemolytic disease in the fetus. Emotional support is critical to address guilt and concerns about the infant's condition.
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Which of the following nursing actions is most effective when evaluating a kinetic family drawing?
- A. telling the child to draw their family doing something
- B. offering specific suggestions of what to include in the drawing
- C. discouraging the child from talking about the drawing
- D. noting the omission of any family members
Correct Answer: D
Rationale: There are several guidelines for evaluating kinetic family drawings, including Choice 4. Effective nursing actions include asking the client to explain what each family member is doing, encouraging him or her to tell as much as possible about the drawing, noting physical intimacy or distance, noting placement of family members in the drawing, noting facial expressions of family members and noting if they are facing each other or turned away. Choice 1 is initial instruction, not evaluation. Only general encouragement should be given to avoid suggesting themes to the child.
Which of these would be the most appropriate way to document a client's refusal of medication?
- A. Heparin refused during shift. Risks reviewed.'
- B. The client refused the heparin injection when I tried to administer it. She yelled at me saying, 'I do not want that injection right now!' and told me to leave the room. I explained the risks of not taking the medication. She seemed very annoyed that I tried to give it at that time. I will attempt again later in my shift.'
- C. Subcutaneous Heparin injection was attempted to be given to the client per the physician's order. Client refused, stating, 'I do not want that injection.' Potential risks for refusing the medication were reviewed with the client and client verbalized understanding.'
- D. Ct stated she did not want the SQ heparin inj at this time. Risks of not taking this med were reviewed with the ct and ct verbalized understanding.'
Correct Answer: C
Rationale: Documentation in healthcare should be objective, thorough, but direct. It should be articulate, with correct grammar and spelling.
Which is the correct order regarding the hierarchy of members of the nursing team from least authority to highest authority?A.staff nurse ,B.nurse manager,C.LPN ,D.charge nurse
- A. A) C, D, A, B
- B. B) A, C, B, D
- C. C) C, A, D, B
- D. D) C, A, B, D
Correct Answer: C
Rationale: Nurse managers oversee charge nurses who oversee staff nurses who oversee LPNs.
Which of the following physical findings indicates that an 11-12-month-old child is at risk for developmental dysplasia of the hip?
- A. refusal to walk
- B. not pulling to a standing position
- C. negative Trendelenburg sign
- D. negative Ortolani sign
Correct Answer: B
Rationale: The nurse might be concerned about developmental dysplasia of the hip if an 11-12-month-old child doesn't pull to a standing position. An infant who does not walk by 15 months of age should be evaluated. Children should start walking between 11-15 months of age. Trendelenberg sign is related to weakness of the gluteus medius muscle, not hip dysplasia. Ortolani sign is used to identify congenital subluxation or dislocation of the hip in infants.
The nurse is caring for a client recovering from a stroke who recently regained consciousness. The client is having difficulty communicating verbally with the team. Which of the following would be least appropriate?
- A. Begin client data collection prior to receiving the physician's order for the referral.
- B. Use documents to contribute information for the referral.
- C. Wait for the physician to order speech therapy and then assist with the appropriate documentation.
- D. Participate in the client referral process.
Correct Answer: C
Rationale: The nurse should participate in the client referral process, collect client data, and use appropriate documents to contribute information. It is not necessary to wait for the physician's order if the nurse recognizes the need for client referral.