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To prevent transmission of bacterial meningitis, the nurse would instruct an infected baby's mother to:
- A. Avoid touching the baby while in the room.
- B. Stay outside of the baby's room.
- C. Wear a gown and gloves and wash her hands before and after leaving the room.
- D. Wear a mask while in the room.
Correct Answer: C
Rationale: The mother should be allowed and encouraged to touch her baby. With care, transmission can be prevented. There is no need for the mother to stay outside the room. Everyone entering the baby's room should take appropriate measures to prevent transmission of pathogens. Wearing a mask will not protect against transmission of pathogens.
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The client at 34 weeks gestation is admitted with a diagnosis of preterm premature rupture of membranes (PPROM). The nurse should monitor for which complication?
- A. Chorioamnionitis
- B. Preterm delivery
- C. Fetal distress
- D. All of the above
Correct Answer: D
Rationale: PPROM increases the risk of chorioamnionitis (infection) preterm delivery (due to loss of amniotic fluid) and fetal distress (from infection or cord compression). All are potential complications requiring monitoring.
When caring for a postoperative cholecystectomy client, the nurse assesses patency and documents drainage of the T-tube. The nurse recognizes that the expected amount of drainage during the first 24 hours postoperatively is:
- A. 50-100 mL
- B. 200-300 mL
- C. 300-500 mL
- D. 1000-1200 mL
Correct Answer: C
Rationale: During the first 24 hours after surgery, the drainage is normally 300-500 mL and then decreases to about 200 mL in 24 hours during the next 3-4 days. This range is the amount of drainage after the first 24 hours postoperatively. During the first 24 hours, it is 300-500 mL. During the first 24 hours after surgery, this range is the expected amount of drainage. The expected amount of drainage during the first 24 hours is 300-500 mL. An output of >500 mL should be reported to the physician, because an occlusion of some type, caused by a retained gallstone or an inflammatory process within the biliary drainage system, is evident.
A client is being treated for congestive heart failure. His medical regimen consists of digoxin (Lanoxin) 0.25 mg po daily and furosemide 20 mg po bid. Which laboratory test should the nurse monitor?
- A. Intake and output
- B. Calcium
- C. Potassium
- D. Magnesium
Correct Answer: C
Rationale: Furosemide is a nonpotassium-sparing loop diuretic. Hypokalemia is a common side effect of furosemide and may enhance digoxin toxicity.
The client at 35 weeks gestation is admitted with a diagnosis of vasa previa. The nurse should monitor for which complication?
- A. Fetal bleeding
- B. Maternal hemorrhage
- C. Preterm labor
- D. Fetal macrosomia
Correct Answer: A
Rationale: Vasa previa involves fetal blood vessels crossing the cervical os risking rupture and fetal bleeding during labor or membrane rupture. Maternal hemorrhage preterm labor and macrosomia are less directly related.
A client is being discharged and will continue enteral feedings at home. Which of the following statements by a family member indicates the need for further teaching?
- A. If he develops diarrhea lasting for more than 2-3 days, I will contact the doctor or nurse.
- B. I should anticipate that he will gain about 1 lb/day now that he is on continuous feedings.
- C. It is important to keep the head of his bed elevated or sit him in the chair during feedings.
- D. I should use prepared or open formula within 24 hours and store unused portions in the refrigerator.
Correct Answer: B
Rationale: Diarrhea is a complication of tube feedings that can lead to dehydration. Diarrhea may be the result of hypertonic formulas that can draw fluid into the bowel. Other causes of diarrhea may be bacterial contamination, fecal impaction, medications, and low albumin. A consistent weight gain of more than 0.22 kg/day (1/2 lb/day) over several days should be reported promptly. The client should be evaluated for fluid volume excess. Elevating the client's head prevents reflux and thus formula from entering the airway. Bacteria proliferate rapidly in enteral formulas and can cause gastroenteritis and even sepsis.