Nokea
The nurse is caring for a client at 12 weeks gestation who has a rubella titer status of nonimmune. Which of the following actions should the nurse anticipate implementing?
- A. Administering measles-mumps-rubella (MMR) vaccine now
- B. Administering MMR vaccine immediately postpartum
- C. Administering MMR vaccine in the third trimester
- D. Informing the client that an MMR vaccine is not indicated
Correct Answer: B
Rationale: MMR is contraindicated during pregnancy due to risks to the fetus. Administering it postpartum ensures immunity for future pregnancies without harming the current pregnancy.
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A child's burn is debrided each day with hydrotherapy to remove the eschar. The child's parents ask why this immersion is necessary. What is the most appropriate response for the nurse to make?
- A. By removing the scab or crusting daily in the special bath, we help prevent infection and then the healthy tissue may be covered by skin grafts.'
- B. By submersion in a whirlpool bath, we can better exercise her limbs to prevent contractures.'
- C. This is a cleansing bath given so that fresh dressings may be applied to the burn areas.'
- D. We decrease her chance of infection by immersion in antibiotic solutions with each debriding bath.'
Correct Answer: A
Rationale: Hydrotherapy removes eschar to prevent infection and prepare for grafting, accurately explaining the procedure's purpose.
The nurse is collecting data from a 30-month-old client. Which of the following findings would require follow-up?
- A. head circumference has increased by 1 inch (2.5 cm) in the past year
- B. current weight is six times greater than birth weight
- C. nighttime bladder control has not been achieved
- D. anterior and posterior fontanels are both fused
Correct Answer: C
Rationale: Lack of nighttime bladder control at 30 months may indicate developmental delay or medical issues, requiring follow-up to assess for underlying causes.
A 20-year-old woman is admitted to the hospital following an accident. Her uncle, a physician from out of state, visits her and asks to see her chart. How should the nurse respond?
- A. Comply with the request and give the chart to the physician
- B. Explain that written permission from his niece is needed first
- C. Suggest that he discuss the case with the attending physician
- D. Give him the chart but do not let him remove it from the nurse's station
Correct Answer: B
Rationale: HIPAA regulations require patient consent for chart access, even by a physician relative, unless they are directly involved in care. Permission from the patient is needed first.
The client is admitted with hypokalemia. An IV of normal saline is infusing at $80 \mathrm{ml} /$ hour with 10 meq of $\mathrm{KCl} /$ hour. Prior to beginning the infusion, the nurse should:
- A. Check the sodium level.
- B. Check the magnesium level.
- C. Check the creatinine level.
- D. Check the calcium level.
Correct Answer: B
Rationale: Hypokalemia is often associated with hypomagnesemia, which can impair potassium correction. Checking the magnesium level ensures effective treatment. Sodium , creatinine , and calcium levels are less directly related to potassium infusion safety.
A client hospitalized with mania is racing wildly about the unit trying to organize the other clients into a game of Ping-Pong. The nurse should:
- A. Send the client to the recreation room for art therapy.
- B. Take the client outside for a walk.
- C. Allow the client to continue because his activities are goal directed.
- D. Suggest that the client do exercises to a video instead.
Correct Answer: B
Rationale: Taking the client for a walk redirects energy safely and reduces stimulation. Art therapy may not engage, continuing the activity risks escalation, and video exercises lack supervision.