Nokea
While assessing an Rh positive newborn whose mother is Rh negative, the nurse recognizes the risk for hyperbilirubinemia. Which of the following should be reported immediately?
- A. Jaundice evident at 26 hours
- B. Hematocrit of 55%
- C. Serum bilirubin of 12 mg
- D. Positive Coombs' test
Correct Answer: C
Rationale: The elevated bilirubin is in the range that requires immediate intervention, such as phototherapy. At a serum bilirubin of 12 mg, the neonate is at risk for the development of kernicterus, or bilirubin encephalopathy. The provider determines the therapy appropriate after reviewing all laboratory findings.
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A client has been on antibiotics for 72 hours for cystitis. Which report from the client requires priority attention by the nurse?
- A. foul smelling urine
- B. burning on urination
- C. elevated temperature
- D. nausea and anorexia
Correct Answer: C
Rationale: Elevated temperature after 72 hours on an antibiotic indicates the antibiotic has not been effective in eradicating the offending organism. The provider should be informed immediately so that an appropriate medication can be prescribed, and complications such as pyelonephritis are prevented.
The nurse is admitting a 3-year-old child who is thought to have meningococcal meningitis. What type of room assignment is most appropriate?
- A. Private room
- B. Semi-private room with a child of the same age
- C. Isolation room
- D. A room close to the nurse's station
Correct Answer: C
Rationale: Meningococcal meningitis is highly contagious, requiring droplet isolation in an isolation room to prevent spread, unlike private or semi-private rooms.
Which interventions are appropriate when caring for a client with acute thrombophlebitis?
- A. Apply cool soaks and keep the client's leg lower than the level of the heart
- B. Increase the client's activity level and encourage leg exercises
- C. Apply cool soaks and administer nitroglycerin
- D. Apply warm soaks and elevate the client's legs higher than the level of the heart
Correct Answer: D
Rationale: To help treat thrombophlebitis, the nurse should prevent venostasis with measures such as applying warm soaks and elevating the client's legs. The client should remain on bed rest during the acute phase, after which the client may begin to walk while wearing antiembolism stockings. Treatment for thrombophlebitis may also include anticoagulants to prolong clotting time.
The client states, 'My discharge plan leaves me with a lot to do. I don't think I can do it. I'm never good at doing things.' The nurse knows the client lacks:
- A. maturation.
- B. organization.
- C. readiness to learn.
- D. self-efficacy.
Correct Answer: D
Rationale: Expressing doubt in ability to manage the discharge plan indicates low self-efficacy, a belief in one's capacity to execute tasks.
Anaphylactic shock is a serious type of blood transfusion reaction.
The pathophysiology of anaphylaxis is
- A. It is treated with adrenalin or epinephrine.
- B. A severe vasoconstriction and profound bronchodilation.
- C. Characterized by presence of rashes all throughout the body.
- D. A profound hypotension due to profound vasodilation and severe bronchoconstriction.
Correct Answer: D
Rationale: Anaphylaxis involves vasodilation and bronchoconstriction, leading to hypotension and respiratory distress.