Nokea
The nurse is reinforcing teaching with a client who has a new prescription for Rh immunoglobulin. The client has an Rh-negative blood type and gave birth 24 hours ago to a newborn who has an Rh-positive blood type. Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I need the medication now because the dose I received during pregnancy was ineffective
- B. I can receive the medication at my follow-up appointment in 6 weeks
- C. I need to have a blood specimen obtained in 3 months to verify that the medication was effective
- D. I will receive the medication to prevent my body from forming antibodies
Correct Answer: D
Rationale: Rh immunoglobulin prevents antibody formation against Rh-positive fetal blood, given within 72 hours postpartum. The prenatal dose is separate, 6 weeks is too late, and 3-month testing is not standard.
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The nurse is reinforcing teaching regarding home oxygen use for a client with emphysema who is using nasal cannula and portable oxygen tank. Which of the following statements by the client would require follow-up? Select all that apply.
- A. I can continue to cook on my gas stove.
- B. I can use a humidifier if my nostrils feel dry.
- C. I need to keep a working fire extinguisher in my home.
- D. I should use a wool blanket on my bed instead of cotton.
- E. I can increase the oxygen flow rate whenever I feel short of breath.
Correct Answer: A,D,E
Rationale: Oxygen therapy is commonly prescribed to improve oxygenation for clients with (or at risk for) hypoxia (eg, emphysema) and to promote comfort in clients receiving palliative/hospice care. Clients requiring long-term oxygen therapy may be prescribed portable oxygen delivery (ie, home oxygen therapy) to allow increased independence in daily life.
The nurse in the outpatient care facility is caring for a client with metastatic lung cancer who received chemotherapy 3 days ago. The client states, 'I have decided that I do not want to continue treatment.' Which of the following responses would be appropriate for the nurse to make?
- A. That is not an easy choice to make. I will notify your health care provider of your decision
- B. Have you considered how this decision might affect your spouse and children?
- C. I do not think it is wise to stop chemotherapy. You will become too sick to enjoy your life
- D. Have you discussed this decision with someone else that you trust?
Correct Answer: A
Rationale: Acknowledging the decision’s difficulty and notifying the provider respects autonomy and ensures follow-up. Other responses judge, guilt, or deflect the client’s choice.
The home health nurse is caring for an 85-year-old client. It would require immediate follow-up if the client is reporting
- A. a painful red area on the buttocks
- B. new onset of dependent edema of the feet
- C. progressive loss of central vision
- D. no memory of activities performed yesterday
Correct Answer: A
Rationale: A painful red area on the buttocks suggests a pressure injury, requiring immediate intervention to prevent worsening. Edema, vision loss, and memory issues are concerning but less urgent.
The nurse is caring for a client with Hodgkin's disease who will be receiving radiation therapy. The nurse recognizes that, as a result of the radiation therapy, the client is most likely to experience
- A. high fever
- B. nausea
- C. face and neck edema
- D. night sweats
Correct Answer: B
Rationale: nausea. Because the client with Hodgkin's disease is usually healthy when therapy begins, the nausea is especially troubling.
Which type of accidental poisoning would the nurse expect to occur in children under age 6?
- A. Oral ingestion
- B. Topical contact
- C. Inhalation
- D. Eye splashes
Correct Answer: A
Rationale: Oral ingestion. Young children are most likely to ingest toxic substances due to their exploratory behavior.