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Fraternal twins are delivered by your Rh-negative patient. Twin A is Rh-positive and twin B is Rh-negative. Prior to administering Rho(D) immune globulin (RhoGAM), the nurse should determine the results of the
- A. direct Coombs test of twin A.
- B. direct Coombs test of twin B.
- C. indirect Coombs test of the mother.
- D. transcutaneous bilirubin level for both twins.
Correct Answer: C
Rationale: The correct answer is C: indirect Coombs test of the mother. This test is crucial to determine if the mother has developed antibodies against the Rh-positive blood of twin A, which could lead to hemolytic disease of the newborn in future pregnancies. A direct Coombs test of twin A or twin B is not relevant in this scenario as it does not provide information about the mother's antibody status. Transcutaneous bilirubin levels are used to monitor jaundice in newborns and not related to Rh incompatibility. In summary, the indirect Coombs test of the mother is the most relevant test to assess the risk of hemolytic disease in future pregnancies.
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A nurse is inserting a catheter into a female patient. When the nurse inserts the catheter, no urine is obtained. The nurse suspects the catheter is not in the urethra. What should the nurse do?
- A. Throw the catheter way and begin again.
- B. Fill the balloon with the recommended sterile water.
- C. Remove the catheter, wipe with alcohol, and reinsert after lubrication.
- D. Leave the catheter in the vagina as a landmark for insertion of a new, sterile catheter.
Correct Answer: C
Rationale: The correct choice is C because if no urine is obtained, it indicates that the catheter is not in the urethra. The nurse should remove the catheter, wipe with alcohol to maintain cleanliness, and reinsert after lubrication to ensure proper placement in the urethra. This step-by-step approach allows for a more accurate catheter insertion and prevents potential complications.
Choice A is incorrect as discarding the catheter and starting over without addressing the issue does not solve the problem. Choice B is incorrect as filling the balloon with sterile water is not relevant to the situation of catheter misplacement. Choice D is incorrect as leaving the catheter in the vagina can lead to infection and is not a recommended practice.
A nurse is designing a form for lesbian, gay,bisexual, and transgender (LGBT) patients. Which design should the nurse use?
- A. Use partnered rather than married.
- B. Use mother rather than father.
- C. Use parents rather than guardian.
- D. Use wife/husband rather than significant other.
Correct Answer: C
Rationale: The correct answer is C: Use parents rather than guardian. This is the most inclusive and respectful choice for LGBT patients as it acknowledges different family structures. LGBT individuals may have non-traditional family dynamics, so using "parents" instead of "guardian" is more appropriate. Option A is incorrect because not all LGBT individuals are in partnerships. Option B is incorrect as it assumes traditional gender roles. Option D is incorrect as not all LGBT individuals may identify with the terms "wife" or "husband."
The nurse is administering eye drops to a patient with glaucoma. After instilling the patients first medication, how long should the nurse wait before instilling the patients second medication into the same eye?
- A. 30 seconds
- B. 1 minute
- C. 3 minutes
- D. 5 minutes
Correct Answer: C
Rationale: The correct answer is C: 3 minutes. After administering the first eye drop, waiting for 3 minutes before instilling the second medication allows for proper absorption and effectiveness of each medication. This interval prevents dilution or interaction between the medications. Option A (30 seconds) is too short, not allowing sufficient time for absorption. Option B (1 minute) is also inadequate for proper absorption. Option D (5 minutes) is unnecessarily long and may lead to patient discomfort or inconvenience.
The nurse is reviewing the health history of a newly admitted patient and reads that the patient has been previously diagnosed with exostoses. How should the nurse accommodate this fact into the patients plan of care?
- A. The nurse should perform the Rinne and Weber tests.
- B. The nurse should arrange for audiometry testing as soon as possible.
- C. The nurse should collaborate with the pharmacist to assess for potential ototoxic medications.
- D. No specific assessments or interventions are necessary to addressing exostoses.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. Exostoses are bony growths in the external auditory canal.
2. These growths can cause narrowing and obstruction of the canal, affecting hearing.
3. Collaborating with the pharmacist to assess for ototoxic medications is crucial to prevent further hearing impairment.
4. Performing Rinne and Weber tests (choice A) and arranging audiometry testing (choice B) are not directly related to exostoses.
5. Ignoring exostoses (choice D) can lead to worsening hearing loss and potential complications.
A nurse is inserting an indwelling urinary catheterfor a male patient. Which action will the nurse take?
- A. Hold the shaft of the penis at a 60-degree angle.
- B. Hold the shaft of the penis with the dominant hand.
- C. Cleanse the meatus 3 times with the same cotton ball from clean to dirty.
- D. Cleanse the meatus with circular strokes beginning at the meatus and working outward.
Correct Answer: D
Rationale: The correct answer is D because cleansing the meatus with circular strokes starting at the meatus and moving outward helps prevent the introduction of bacteria into the urethra. This technique minimizes the risk of urinary tract infections. Holding the shaft at a 60-degree angle (A) or with the dominant hand (B) is not necessary for catheter insertion. Cleansing the meatus 3 times with the same cotton ball (C) can introduce more bacteria and is not recommended.