Practice Test Flashcards

The physician has ordered an injection of RhoGam for the postpartum client whose blood type is A negative but whose baby is O positive. To provide postpartum prophylaxis, RhoGam should be administered:

Answer: Within 72 hours of delivery

RhoGam (Rh immune globulin) is administered to Rh-negative mothers who have given birth to an Rh-positive baby to prevent Rh sensitization. For postpartum prophylaxis, it is crucial to administer RhoGam within 72 hours of delivery. This timeframe is critical for preventing the mother's immune system from developing antibodies against Rh-positive fetal red blood cells, which could affect future pregnancies.

The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:

Answer: Reposition the client

Variable decelerations on a fetal monitor strip are often caused by umbilical cord compression. The most appropriate initial nursing action to alleviate this compression and improve fetal oxygenation is to reposition the client, typically to a side-lying position. This simple intervention can often relieve pressure on the cord and resolve the decelerations, making it the priority before more invasive actions.

A client is admitted to the labor and delivery unit complaining of vaginal bleeding with very little discomfort. The nurse’s first action should be to:

Answer: Assess the fetal heart tones

In a pregnant client complaining of vaginal bleeding, the immediate priority is to assess the well-being of the fetus. Checking fetal heart tones (FHTs) provides crucial information about the fetal status and helps determine the urgency of the situation. While other assessments are important, ensuring fetal viability and detecting distress takes precedence in cases of vaginal bleeding.

The nurse is caring for a client admitted with epiglottitis. Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available?

Answer: A tracheostomy set

Epiglottitis is a severe inflammatory condition that can rapidly lead to complete airway obstruction due to swelling of the epiglottis. Given the high risk of sudden and complete airway closure, a tracheostomy set must be immediately available at the bedside. This ensures that an emergency airway can be established if intubation becomes impossible or unsuccessful, preventing respiratory arrest.

A child is admitted to the hospital with a diagnosis of Wilms tumor, stage II. Which of the following statements most accurately describes this stage?

Answer: The tumor extended beyond the kidney but was completely resected

Wilms tumor staging is crucial for determining treatment and prognosis. Stage II Wilms tumor is characterized by the tumor extending beyond the kidney into surrounding tissues, but it has been completely resected during surgery. This means that all visible tumor tissue was removed, distinguishing it from Stage I (confined to the kidney) and higher stages where resection is incomplete or metastasis has occurred.

A child has recently been diagnosed with Duchenne’s muscular dystrophy. The parents are receiving genetic counseling prior to planning another pregnancy. Which of the following statements includes the most accurate information?

Answer: Duchenne’s is an X-linked recessive disorder, so daughters have a 50% chance of being carriers and sons a 50% chance of developing the disease.

Duchenne's muscular dystrophy is an X-linked recessive disorder, meaning the gene responsible is located on the X chromosome. If the mother is a carrier, each son has a 50% chance of inheriting the affected X chromosome and developing the disease. Each daughter has a 50% chance of inheriting the affected X chromosome and becoming a carrier, as they typically need two affected X chromosomes to manifest the disease.

The client is admitted for an open reduction internal fixation of a fractured hip. Immediately following surgery, the nurse should give priority to assessing the:

Answer: Serum collection (Davol) drain

Immediately following an open reduction internal fixation (ORIF) of a fractured hip, assessing the serum collection drain (e.g., Davol or Hemovac) is a priority. This drain removes excess blood and fluid from the surgical site, preventing hematoma formation and reducing the risk of infection and swelling. Monitoring the amount and type of drainage provides critical information about potential hemorrhage and fluid balance, which is vital in the immediate postoperative period.

The nurse is assigned to care for the client with a Steinmann pin. During pin care, she notes that the LPN uses sterile gloves and Q-tips to clean the pin. Which action should the nurse take at this time?

Answer: Assisting the LPN with opening sterile packages and peroxide

Pin care for a Steinmann pin requires strict aseptic technique to prevent infection at the pin insertion site, as it provides a direct pathway for bacteria into the bone. The LPN correctly using sterile gloves and Q-tips indicates an understanding of sterile technique. The nurse's role is to support and facilitate this correct practice, such as by assisting with opening sterile packages and providing supplies like peroxide, rather than suggesting less sterile methods.

The elderly client is admitted to the emergency room. Which symptom is the client with a fractured hip most likely to exhibit?

Answer: Disalignment

A fractured hip in an elderly client typically presents with characteristic disalignment of the affected extremity. This often includes external rotation, shortening, and adduction of the leg, which are direct physical signs of bone displacement. While pain is certainly present, disalignment is a specific and highly indicative physical finding of a hip fracture.

He knows that there are external forces that influence changes in his unit. Which of the following is NOT an external force?

Answer: Low morale of staff in her unit

External forces influencing change originate from outside the organization or unit. Examples include regulatory standards, economic pressures, or demands from external stakeholders like labor unions or the CEO. Low morale of staff, however, is an internal issue originating within the unit itself, reflecting the internal environment rather than an external influence.

After discussing the possible effects of the low patient satisfaction rate, the staff started to list down possible strategies to solve the problems head-on. Should they decide to vote on the best change strategy, which of the following strategies is referred to this?

Answer: Majority rule

When a group decides to 'vote on the best change strategy,' they are employing the decision-making method of majority rule. This strategy involves making a decision based on the preference of more than half of the group members. It is a common and efficient way to reach a conclusion when consensus is not achievable or practical.

One staff suggests that they review the pattern of nursing care that they are using, which is described as a:

Answer: system used to deliver care

A 'pattern of nursing care' or a 'nursing care delivery system' refers to the organizational framework that dictates how nursing care is provided to patients. This includes how nurses are assigned, how responsibilities are distributed, and how communication flows within the care team. It is essentially the structure and process by which patient care is delivered, not merely a job description or a manual.

Which of the following is TRUE about functional nursing?

Answer: Concentrates on tasks and activities

Functional nursing is a care delivery model where nursing tasks are divided among staff members, and each person is responsible for completing specific tasks for a group of patients (e.g., one nurse gives all medications, another does all treatments). This model is highly task-oriented and efficient for specific activities but can lead to fragmented care and less holistic patient interaction.

He raised the issue on giving priority to patient needs. Which of the following offers the best way for setting priority?

Answer: Assessing nursing needs and problems

The best way to set priorities for patient needs is to first thoroughly assess those needs and problems. A comprehensive assessment provides the foundational data necessary to identify what issues are most critical, urgent, or life-threatening. Without a proper assessment, any attempt to prioritize care would be arbitrary and potentially unsafe, leading to suboptimal patient outcomes.

Which of the following is the best guarantee that the patient’s priority needs are met?

Answer: Preparing a nursing care plan in collaboration with the patient

The best guarantee that a patient's priority needs are met is through the collaborative development of a nursing care plan with the patient. Involving the patient ensures that their unique perspectives, values, and preferences are incorporated into the plan, making it person-centered and more likely to be effective and adhered to. This approach promotes patient autonomy and better outcomes.

When Henry uses team nursing as a care delivery system, he and his team need to assess the priority of care for a group of patients, which of the following should be a priority?

Answer: Patients who need the most care

In team nursing, when assessing the priority of care for a group of patients, the highest priority should always be given to patients who need the most care. This typically includes patients who are unstable, critically ill, have complex needs, or require immediate interventions to prevent deterioration. This approach ensures that resources are allocated effectively to those with the greatest need.