Nokea
The nurse gives a 35-year-old primigravida client a RhoGAM injection in her 27th week of pregnancy. Which of the following client situations requires the nurse to take this action?
- A. Rh-negative mother and Rh-positive father
- B. Rh-negative mother and Rh-negative father
- C. Rh-positive mother and Rh-negative father
- D. Rh-positive mother and Rh-positive father
Correct Answer: A
Rationale: RhoGAM is given to an Rh-negative mother with an Rh-positive father to prevent Rh incompatibility issues in the fetus.
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The physician has ordered cortisporin ear drops for a 2-year-old. To administer the ear drops, the nurse should:
- A. Pull the ear down and back
- B. Pull the ear straight out
- C. Pull the ear up and back
- D. Leave the ear undisturbed
Correct Answer: A
Rationale: For children under 3, pulling the ear down and back straightens the ear canal for proper administration of ear drops.
The nurse should visit which of the following clients first?
- A. The client with diabetes with a blood glucose of 95 mg/dL
- B. The client with hypertension being maintained on Lisinopril
- C. The client with chest pain and a history of angina
- D. The client with Raynaud's disease
Correct Answer: C
Rationale: Chest pain in a client with a history of angina suggests possible cardiac ischemia, requiring immediate assessment.
A client is admitted with a diagnosis of duodenal ulcer. A common complaint of the client with a duodenal ulcer is:
- A. Epigastric pain that is relieved by eating
- B. Weight loss
- C. Epigastric pain that is worse after eating
- D. Vomiting after eating
Correct Answer: A
Rationale: Duodenal ulcers typically cause epigastric pain that is relieved by eating due to buffering of gastric acid.
The nurse is caring for a female client following the removal of the parathyroid glands. The client complains of a 'pins and needles' sensation and difficulty swallowing lunch. The nurse would expect which laboratory value to be abnormal?
- A. calcium
- B. potassium
- C. magnesium
- D. blood glucose
Correct Answer: A
Rationale: Parathyroidectomy can cause hypocalcemia, leading to paresthesia ('pins and needles') and dysphagia due to muscle dysfunction.
The nurse is caring for a client with a wound that presents with full-thickness tissue loss and eschar covering the wound bed. The nurse would record this wound as which stage?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
- E. unstageable
Correct Answer: E
Rationale: A wound with eschar covering the bed is unstageable because the depth cannot be assessed until the eschar is removed.