Nokea
The nurse is informed that a newborn infant whose mother is Rh negative will be admitted to the nursery. When planning care for the infant's arrival, which action should the nurse take?
- A. Obtain the newborn infant's blood type and direct Coombs' results from the laboratory.
- B. Obtain the necessary equipment from the blood bank needed for an exchange transfusion.
- C. Call the maintenance department and ask for a phototherapy unit to be brought to the nursery.
- D. Obtain a vial of vitamin K from the pharmacy and prepare to administer an injection to prevent isoimmunization.
Correct Answer: A
Rationale: To further plan for the newborn infant's care, the infant's blood type and direct Coombs' results must be known. Umbilical cord blood is taken at the time of delivery to determine blood type, Rh factor, and antibody titer (direct Coombs' test) of the newborn infant. The nurse should obtain these results from the laboratory. Options 2 and 3 are inappropriate at this time, and additional data are needed to determine whether these actions are needed. Option 4 is incorrect because vitamin K is given to prevent hemorrhagic disease of the newborn infant.
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A nursing student is asked to conduct a clinical conference about autism. Which characteristic associated with autism should the student plan to include?
- A. Normal social play that ceases by age 5
- B. Lack of social interaction and awareness
- C. The consistent imitation of others' actions
- D. Normal verbal but abnormal nonverbal communication
Correct Answer: B
Rationale: Autism is a severe developmental disorder that begins in infancy or toddlerhood. A primary characteristic is a lack of social interaction and awareness. Social behaviors in children with autism include a lack of or abnormal imitations of others' actions and a lack of or abnormal social play. Additional characteristics include a lack of or impaired verbal communication and marked abnormal nonverbal communication.
The nurse is receiving a client from the emergency department who has a diagnosis of Guillain-Barré syndrome. The client's chief sign/symptom is an ascending paralysis that has reached the level of the waist. Which items should the nurse plan to have available for emergency use?
- A. Nebulizer and pulse oximeter
- B. Blood pressure cuff and flashlight
- C. Flashlight and incentive spirometer
- D. Cardiac monitor and intubation tray
Correct Answer: D
Rationale: The client with Guillain-Barré syndrome is at risk for respiratory failure as a result of ascending paralysis. An intubation tray should be available for emergency use. Another complication of this syndrome is cardiac dysrhythmias, which necessitates the need for cardiac monitoring. Although some of the items in the remaining options may be kept at the bedside (e.g., pulse oximeter, blood pressure cuff, flashlight), they are not necessarily needed for emergency use in this situation.
The nurse is caring for a client diagnosed with dementia. Which nutritional goal should the nurse plan for with this client?
- A. Client will be free of hallucinations.
- B. Client will feed self with cueing within 24 hours.
- C. Client will be able to prepare simple foods by discharge.
- D. Client will identify favorite foods by the time of discharge.
Correct Answer: B
Rationale: The correct option identifies a goal that is directly related to the client's ability to care for self. None of the remaining options are related to the client's self-care needs.
The nurse is creating a plan of care for a client prescribed bed rest. Which intervention should the nurse include in the plan to limit the complications of prolonged immobility?
- A. Maintain the client in a supine position.
- B. Provide a daily fluid intake of 1000 mL.
- C. Limit the intake of milk and milk products.
- D. Monitor for signs of a low serum calcium level.
Correct Answer: C
Rationale: The formation of renal and urinary calculi is a complication of immobility. Limiting milk and milk products is the best measure to prevent the formation of calcium stones. A supine position increases urinary stasis; therefore, this position should be limited or avoided. Daily fluid intake should be 2000 mL or more per day. The nurse should monitor for signs and symptoms of hypercalcemia, such as nausea, vomiting, polydipsia, polyuria, and lethargy.
Which items should the nurse plan to provide to optimally maintain the integrity of a set of arterial blood gas measurements?
- A. A syringe that contains a preservative
- B. A heparinized syringe and a bag of ice
- C. A heparinized syringe and a preservative
- D. A syringe that contains a preservative and a bag of ice
Correct Answer: B
Rationale: The arterial blood gas sample is obtained using a heparinized syringe. The sample of blood is placed on ice and sent to the laboratory immediately. A preservative is not used.