Nokea
Which of the following nursing orders should be included in the plan of care for a client with hepatitis C?
- A. The nurse should use universal precautions when obtaining blood samples.
- B. Total bed rest should be maintained until the client is asymptomatic.
- C. The client should be instructed to maintain a low semi-Fowler position when eating meals.
- D. The nurse should administer an alcohol backrub at bedtime.
Correct Answer: A
Rationale: Universal precautions are critical due to the bloodborne nature of hepatitis C. The other options are not appropriate for hepatitis C care.
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A 9-month-old infant was diagnosed with nonorganic failure to thrive. During her hospitalization, primary nurses were assigned to initiate all infant feedings. The infant's parents question why they cannot feed their own child. Which of the following responses would be most appropriate by the nurse?
- A. By assigning the same nurses to the child, the nurses can begin to learn the infant's cues and feeding behaviors.
- B. The same nurses will prevent parental fatigue and frustration.
- C. The same nurses will prevent infant fatigue and frustration.
- D. Primary nurses will ensure privacy.
Correct Answer: A
Rationale: Consistent primary care nurses can better interpret infant cues and note feeding behaviors, which is critical in managing nonorganic failure to thrive.
A pregnant client comes to the office for her first prenatal examination at 10 weeks. She has been pregnant twice before; the first delivery produced a viable baby girl at 39 weeks 3 years ago; the second pregnancy produced a viable baby boy at 36 weeks 2 years ago. Both children are living and well. Using the gravida and para system to record the client's obstetrical history, the nurse should record:
- A. Gravida 3 para 1
- B. Gravida 3 para 2
- C. Gravida 2 para 1
- D. Gravida 2 para 2
Correct Answer: B
Rationale: Gravida=3 (current pregnancy), Para=2 (two births after 20 weeks).
A primigravida is at term. The nurse can recognize the second stage of labor by the client's desire to:
- A. Push during contractions
- B. Hyperventilate during contractions
- C. Walk between contractions
- D. Relax during contractions
Correct Answer: A
Rationale: The second stage of labor is marked by full cervical dilation and the urge to push with contractions.
A patient with thrombocytopenia has a platelet count of 80,000. It will be most important to teach the client about:
- A. Measures to reduce the risk of bleeding
- B. Increasing the fluid intake
- C. Activities to improve oxygenation
- D. Ways to conserve energy
Correct Answer: A
Rationale: Thrombocytopenia (low platelet count) increases bleeding risk. Teaching measures to reduce bleeding (e.g. avoiding trauma using soft toothbrushes) is critical. Fluid intake oxygenation and energy conservation are less directly related to the condition.
Proper positioning for the child who is in Bryant's traction is:
- A. Both hips flexed at a 90-degree angle with the knees extended and the buttocks elevated off the bed
- B. Both legs extended, and the hips are not flexed
- C. The affected leg extended with slight hip flexion
- D. Both hips and knees maintained at a 90-degree flexion angle, and the back flat on the bed
Correct Answer: A
Rationale: The child's weight supplies the countertraction for Bryant's traction; the buttocks are slightly elevated off the bed, and the hips are flexed at a 90-degree angle. Both legs are suspended by skin traction. The child in Buck's extension traction maintains the legs extended and parallel to the bed. The child in Russell traction maintains hip flexion of the affected leg at the prescribed angle with the leg extended. The child in '90-90' traction maintains both hips and knees at a 90-degree flexion angle and the back is flat on the bed.