Nokea
The nurse has provided an in-service presentation to ancillary staff about standard precautions on the birthing unit. The nurse determines that one of the staff members needs further instructions when the nurse observes which of the following?
- A. Use of protective goggles during a cesarean delivery.
- B. Placement of bloody sheets in a container designated for contaminated linens.
- C. Wearing of sterile gloves to bathe a newly delivered neonate at 1 hour of age.
- D. Disposal of used scalpel blades in a puncture-resistant container.
Correct Answer: C
Rationale: Sterile gloves are unnecessary for bathing a neonate; clean gloves suffice, indicating a need for further instruction on standard precautions.
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A client is admitted with acute glomerulonephritis. The nurse should monitor the client for which of the following?
- A. Hypertension.
- B. Hypokalemia.
- C. Polyuria.
- D. Hypoalbuminemia.
Correct Answer: A, D
Rationale: Acute glomerulonephritis can cause hypertension (due to fluid retention) and hypoalbuminemia (due to proteinuria).
The nurse finds a sealed container of I.V. 50% dextrose in a waste bin on the nursing unit. The nurse should:
- A. Leave it where found and notify risk management.
- B. Send it to the pharmacy.
- C. File an incident report.
- D. Discard it in a sharps container.
Correct Answer: C
Rationale: Filing an incident report addresses the improper disposal of a medication, ensuring investigation and prevention of future errors.
After teaching a mother about the neonate's positive Babinski's reflex, the nurse determines that the mother understands the instructions when she says that a positive Babinski's reflex indicates:
- A. Possible partial paralysis.
- B. Possible lower limb defect.
- C. Immature central nervous system.
- D. Possible injury to nerves that innervate the legs.
Correct Answer: C
Rationale: A positive Babinski's reflex in neonates indicates an immature central nervous system, a normal finding that typically disappears by 1–2 years.
The client with a nasogastric (NG) tube begins to complain of abdominal distention. Which of the following measures should the nurse implement first?
- A. Call the physician.
- B. Irrigate the NG tube.
- C. Check the function of the suction equipment.
- D. Reposition the NG tube.
Correct Answer: C
Rationale: Checking the suction equipment ensures the NG tube is functioning properly, addressing the most likely cause of distention before escalating to other interventions.
The nurse has an order to administer ampicillin (Omnipen) 250 mg I.M. After reconstituting the ampicillin with sterile water for injection, the solution available is 500 mg/mL. How many milliliters should the nurse administer?
- A. 0.5 mL.
- B. 1 mL.
- C. 2 mL.
- D. 1.5 mL.
Correct Answer: A
Rationale: To administer 250 mg from a 500 mg/mL solution, the calculation is 250 mg / 500 mg/mL = 0.5 mL.