Nokea
For which of the following mother-baby pairs should the nurse review the Coombs' test in preparation for administering Rh0 (D) immune globulin within 72 hours of birth?
- A. Rh negative mother with Rh positive baby
- B. Rh negative mother with Rh negative baby
- C. Rh positive mother with Rh positive baby
- D. Rh positive mother with Rh negative baby
Correct Answer: A
Rationale: Rh negative mother with Rh positive baby. Rh0 (D) immune globulin is administered to prevent Rh sensitization in an Rh-negative mother who may have been exposed to Rh-positive fetal blood during delivery. The Coombs' test helps determine if the baby is Rh-positive, confirming the need for the injection.
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A patient with a cuffed tracheostomy tube in place after surgery.
The nurse knows the purpose of the cuff on the tracheostomy tube is to
- A. guarantee secure placement of the tracheostomy tube in the airway.
- B. prevent ischemia of the tracheal wall by distributing the pressure applied to it.
- C. decrease the chance of aspiration into the trachea.
- D. protect the trachea from ischemia and edema.
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) inaccurate, not the purpose of the cuff on a tracheostomy tube (2) complication of using a cuffed tracheostomy tube (3) correct-seals trachea, helps to prevent aspiration (4) trauma from overinflated tube may cause edema
The nurse is caring for a client who is 2 days postoperative after a cholecystectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 99.5°F (37.5°C).
- B. Pain at the incision site.
- C. Yellowish drainage from the incision.
- D. Urine output of 1500 mL in 24 hours.
Correct Answer: C
Rationale: Yellowish drainage from the incision suggests infection or bile leakage, a serious complication post-cholecystectomy requiring immediate evaluation. Options A, B, and D are expected or normal: slight fever is common, incision pain is typical, and urine output is adequate.
A male client's behavior begins to escalate into aggressive behavior.
The nurse is caring for clients on the psychiatric unit. Suddenly, a male client's behavior begins to escalate into aggressive behavior. It would be MOST important for the nurse to take which of the following actions?
- A. Utilize an organized team to place the client in seclusion.
- B. Leave the client alone in his room to identify feelings of anger.
- C. Redirect the client to a quiet activity to divert his attention and not disturb the other clients.
- D. Assist the client to identify and express his feelings of increasing anxiety, frustration, and anger.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) nurse can be helpful in using psychological/communication strategies before utilizing seclusion (2) leaving the client alone can become potentially dangerous to the client and the property (3) encouraging the client to become involved in a quiet activity might further escalate his frustration and anger because the ability to focus and concentrate is diminished due to an elevated anxiety level (4) correct-as client's anger begins to escalate, nurse can be helpful in using psychological/communication strategies before utilizing seclusion
A client was admitted to the psychiatric unit after complaining to her friends and family that neighbors have bugged her home in order to hear all of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately focus on efforts to
- A. Convince the client that the hospital staff is trying to help
- B. Help the client to enter into group recreational activities
- C. Provide interactions to help the client learn to trust staff
- D. Arrange the environment to limit the client's contact with other clients
Correct Answer: C
Rationale: Provide interactions to help the client learn to trust staff. Establishing trust helps clients feel safer and facilitates a therapeutic alliance between staff and client.
A male client is admitted with urinary tract problems. A prostate-specific antigen (PSA) and acid phosphatase Test are to be done.
The nurse knows that
- A. these Test s are valuable screening Test s for prostatic cancer.
- B. the level of PSA is decreased in clients with renal stones.
- C. the level reflects the level of renal involvement in acid-base problems.
- D. the level of PSA is elevated in clients in early stage renal failure.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-PSA Test has replaced acid phosphatase Test in screening for prostatic cancer; Test must be drawn before digital rectal exam, as manipulation of the prostate will abnormally increase PSA value (2) inaccurate information about a PSA (3) inaccurate information about a PSA (4) inaccurate information about a PSA