Nokea
The nurse takes a history from a woman in the prenatal clinic. The nurse identifies that which of the following pregnant women is MOST likely to have an Rh-incompatibility problem?
- A. An Rh-positive woman pregnant for the third time who conceived with an Rh-negative man and never has received RhoGAM.
- B. An Rh-negative woman who conceived with an Rh-positive man who has Rh antibodies.
- C. An Rh-positive woman who previously aborted a fetus at 12 weeks gestation and did not receive RhoGAM and now conceived with an Rh-positive man.
- D. An Rh-negative woman who never received RhoGAM and now conceived with an Rh-negative man.
Correct Answer: B
Rationale: Rh-positive dominant, fetus will be Rh-positive, Rh antibodies from the mother will break down fetus's blood cells
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The nurse observes a student nurse checking the placement of a nasogastric (NG) tube. Which of the following actions, if performed by the student nurse, would require an intervention by the nurse?
- A. Places the end of the NG tube in a cup of water and watches for bubble formation.
- B. Checks the pH of the contents aspirated from the NG tube.
- C. Positions a stethoscope on the upper abdomen and listens as air is introduced into the NG tube.
- D. Uses a large barreled syringe to aspirate for stomach contents.
Correct Answer: A
Rationale: not considered acceptable procedure
When assessing orientation to person, place, and time for an elderly hospitalized client, which of the following principles should be understood by the nurse?
- A. Short-term memory is more efficient than long-term memory.
- B. The stress of an unfamiliar environment may cause confusion.
- C. A decline in mental status is a normal part of aging.
- D. Learning ability is reduced during hospitalization of the elderly client.
Correct Answer: B
Rationale: stress of an unfamiliar situation or environment may lead to confusion in elderly clients
The nurse is making patient assignments on a medical/surgical unit. The staff includes one RN, one RN pulled from the pediatric floor, an LPN/LVN, and a nursing assistant. Which of the following patients should be assigned to the RN from the pediatric floor?
- A. A client one-day postoperative after an appendectomy.
- B. A client who had a detached retina surgically repaired 4 hours ago.
- C. A client with a Sengstaken-Blakemore tube in place.
- D. A client two-days postoperative after a laminectomy with spinal fusion.
Correct Answer: A
Rationale: stable patient with expected outcome
A young child is placed on droplet precautions. The nurse is caring for which of the following clients?
- A. A child with cystic fibrosis.
- B. A child with tonsillitis.
- C. A child with bronchitis.
- D. A child with pertussis.
Correct Answer: D
Rationale: droplet precautions required, private room, maintain spatial separation of 3 feet between patient and visitors
The lab reports a lecithin/sphingomyelin (L/S) ratio of 3:1 for a client who has been on bedrest 48 hours in an unsuccessful attempt to arrest premature labor at 33-weeks gestation. Based on this result, the nurse would anticipate
- A. administration of ritodrine hydrochloride (Yutopar).
- B. initiation of an oxytocin (Pitocin) drip.
- C. delivery of the infant by cesarean section.
- D. continuation of bedrest until otherwise indicated.
Correct Answer: C
Rationale: because the lungs are adequately mature, there is no need to attempt to postpone labor; delivery by cesarean section is generally preferred for preterm infants