Nokea
Which procedure should be avoided in order to help prevent the transmission of the human immunodeficiency virus (HIV) from a positive pregnant mother to her fetus during the intrapartum period?
- A. Cesarean birth
- B. Epidural anesthesia
- C. External fetal heart rate monitoring
- D. Direct (internal) fetal heart rate monitoring
Correct Answer: D
Rationale: Health care professionals must use caution during the intrapartal period to reduce the risk of the transmission of HIV to the fetus. Any procedure that exposes blood or body fluids from the mother to the fetus should be avoided. Direct (internal) fetal monitoring is a procedure that may expose the fetus to maternal blood or body fluids and therefore should be avoided. None of the remaining options are invasive measures that place the fetus at risk in the intrapartum period.
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The nurse is monitoring a client who is receiving a blood transfusion when the client reports diaphoresis, warmth, and a backache. The nurse should take which actions? Select all that apply.
- A. Remove the IV catheter.
- B. Document the occurrence.
- C. Stop the blood transfusion.
- D. Contact the primary health care provider.
- E. Hang 0.9% sodium chloride solution.
Correct Answer: B,C,D,E
Rationale: If a client experiences diaphoresis, warmth, and a backache, a transfusion reaction is suspected. The nurse stops the transfusion and prevents the infusion of any additional blood; then the nurse hangs a bag of 0.9% sodium chloride solution. This maintains IV access and helps maintain the client's intravascular volume. The primary health care provider is notified, as is the blood bank. The nurse also documents the occurrence, the actions taken, and the client's response. To preserve the IV access, the nurse should not remove the catheter and discontinue the IV site.
When educating unlicensed assistants on how to prevent the development of pressure ulcers, the nurse should emphasize that most tissue injuries related to shearing can be prevented by implementing which of the following activities?
- A. Close adherence to a turning schedule
- B. Keeping the skin clean and dry
- C. Proper positioning and moving of the client
- D. Use of skin lubricants
Correct Answer: C
Rationale: Proper positioning and moving techniques prevent shearing injuries, which occur when skin slides over a surface, damaging tissue. Turning schedules and clean skin help but are less specific to shearing.
Thirty minutes after a Sengstaken-Blakemore tube is inserted, the nurse observes that the client appears to be having difficulty breathing. The nurse's first action should be to:
- A. Remove the tube.
- B. Deflate the esophageal portion of the tube.
- C. Determine whether the tube is obstructing the airway.
- D. Increase the oxygen flow rate.
Correct Answer: C
Rationale: Difficulty breathing may indicate airway obstruction by the Sengstaken-Blakemore tube, so assessing this is the priority action.
A client with a history of type 2 diabetes is prescribed metformin (Glucophage). The nurse should instruct the client to:
- A. Take the medication with meals.
- B. Avoid alcohol consumption.
- C. Take the medication at bedtime.
- D. Stop the medication if nausea occurs.
Correct Answer: A, B
Rationale: Metformin should be taken with meals to reduce gastrointestinal upset, and alcohol should be avoided to prevent lactic acidosis.
A primary concern of the hospitalized adolescent is:
- A. Respect for the need for privacy.
- B. Allowing parents to visit after hours.
- C. Wearing a hospital gown.
- D. The fear of loss of control when in pain.
Correct Answer: A
Rationale: Adolescents value autonomy and privacy, which is a primary concern during hospitalization, as it supports their developmental need for independence.