Planning
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Question 1 of 5.
The nurse is informed that a newborn infant whose mother is Rh negative will be admitted to the nursery. When planning care for the infant's arrival, which action should the nurse take?
A. Obtain the newborn infant's blood type and direct Coombs' results from the laboratory.
B. Obtain the necessary equipment from the blood bank needed for an exchange transfusion.
C. Call the maintenance department and ask for a phototherapy unit to be brought to the nursery.
D. Obtain a vial of vitamin K from the pharmacy and prepare to administer an injection to prevent isoimmunization.
Explanation: To further plan for the newborn infant's care, the infant's blood type and direct Coombs' results must be known. Umbilical cord blood is taken at the time of delivery to determine blood type, Rh factor, and antibody titer (direct Coombs' test) of the newborn infant. The nurse should obtain these results from the laboratory. Options 2 and 3 are inappropriate at this time, and additional data are needed to determine whether these actions are needed. Option 4 is incorrect because vitamin K is given to prevent hemorrhagic disease of the newborn infant.
Question 2 of 5.
The nurse is caring for a client who is receiving total parenteral nutrition through a central venous catheter. Which action should the nurse plan to implement to decrease the risk of infection in this client?
A. Track the client's oral temperature.
B. Administer antibiotics intravenously.
C. Evaluate the differential of the leukocytes.
D. Use sterile technique for dressing changes.
Explanation: Sterile technique is vital during dressing changes of a central venous catheter (CVC). CVCs are large-bore catheters that can serve as a direct-entry point for microorganisms into the heart and circulatory system. Using aseptic technique helps avoid catheter-related infections by preventing the introduction of potential pathogens to the site. Although the remaining options are reasonable nursing interventions for a client with a CVC, none of them prevents infection. Options 1 and 3 are assessment methods, and option 2 is implemented after the confirmation of an existing infection.
Question 3 of 5.
The nurse creates a plan of care for a client with a spica cast that covers a lower extremity. Which action should the nurse include in the plan of care to promote bowel elimination?
A. Use a bedside commode.
B. Ambulate to the bathroom.
C. Administer an enema daily.
D. Use a low-profile (fracture) bedpan.
Explanation: A client with a spica cast (body cast) that covers a lower extremity cannot bend at the hips to sit up. A low-profile bedpan or fracture pan is designed for use by clients with body or leg casts and for clients who have difficulty raising the hips to use a standard bedpan; therefore, using a commode or the bathroom is contraindicated. Daily enemas are not a part of routine care.
Question 4 of 5.
The nurse is caring for a postpartum client with thromboembolytic disease. Which intervention is most important to include when planning care to prevent the complication of pulmonary embolism?
A. Enforce bed rest.
B. Monitor the vital signs frequently.
C. Assess the breath sounds frequently.
D. Administer prescribed anticoagulant therapy.
Explanation: The purposes of anticoagulant therapy for the treatment of thromboembolytic disease are to prevent the formation of a clot and to prevent a clot from moving to another area, thus preventing pulmonary embolism. Although the remaining options may be implemented for a client with thromboembolytic disease, the correct option will specifically assist in the prevention of pulmonary embolism.
Question 5 of 5.
The student nurse is listening to a lecture on serum electrolyte levels and the use of isotonic solutions. Which statement by the student nurse indicates that the teaching has been effective?
A. 10% dextrose in water is a hypotonic solution.
B. 3% sodium chloride solution is a hypotonic solution.
C. 5% dextrose in water is considered an isotonic solution.
D. 0.45% sodium chloride solution is a hypertonic solution.
Explanation: Five percent dextrose in water is an isotonic solution, which means that the osmolality of this solution matches normal body fluids. Other examples of isotonic fluids include 0.9% sodium chloride solution (normal saline) and lactated Ringer's solution. Ten percent dextrose in water and 3% sodium chloride solution are hypertonic solutions, and 0.45% sodium chloride solution is hypotonic.
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