Nursing Elites

1. A client with blood type AB negative delivers a newborn with blood type A positive. The cord blood reveals a positive indirect Coombs test. Which is the implication of this finding?

• A. The newborn is infected with an infectious blood-borne disease
• B. The newborn needs phototherapy for physiologic jaundice
• C. The mother's Rh antibodies are present in the neonatal blood
• D. The mother no longer needs Rho immune globulin injections

Correct answer: C

Rationale: A positive indirect Coombs test indicates that the mother's Rh antibodies have crossed the placenta and are present in the neonatal blood, which can lead to hemolytic disease of the newborn. This finding necessitates close monitoring and potential intervention. Choice A is incorrect because a positive Coombs test does not indicate an infectious blood-borne disease. Choice B is incorrect as phototherapy for physiologic jaundice is not related to a positive Coombs test result. Choice D is incorrect because a positive Coombs test does not indicate that the mother no longer needs Rho immune globulin injections; in fact, it suggests a need for further management to prevent hemolytic disease of the newborn.

2. After adding feeding solution to a client's tube feeding system as seen in the picture, what action should the PN take next?

• A. Remove the air from the solution bag
• B. Obtain a piston syringe and irrigation set
• C. Record the solution added as fluid intake
• D. Calculate the rate of flow of the solution

Correct answer: B

Rationale: After adding feeding solution, obtaining a piston syringe and irrigation set is necessary to flush the feeding tube and ensure patency before starting the feeding. This helps prevent blockages and ensures proper delivery of the nutritional solution. Option A is incorrect because removing air from the solution bag is not the immediate next step after adding the feeding solution. Option C is incorrect as recording the solution added as fluid intake is important but not the immediate next step. Option D is incorrect as calculating the rate of flow of the solution is not the next step after adding the feeding solution.

3. A client who is post-operative from a bowel resection is experiencing abdominal distention and pain. The nurse notices the client has not passed gas or had a bowel movement. What should the nurse assess first?

• A. The client's bowel sounds.
• B. The client's fluid intake.
• C. The client's pain level.
• D. The client's surgical incision.

Correct answer: A

Rationale: Assessing bowel sounds is crucial in this situation as it helps determine if the client's gastrointestinal tract is functioning properly. Absent or hypoactive bowel sounds can indicate an ileus, a common post-operative complication. Assessing fluid intake (Choice B) is important but should come after assessing bowel sounds. Pain assessment (Choice C) is essential but addressing the physiological issue should take precedence. Checking the surgical incision (Choice D) is relevant but not the priority when the client is experiencing abdominal distention and potential gastrointestinal complications.

4. A client who had a thyroidectomy 24 hours ago reports tingling around the mouth and in the fingertips. What should the nurse do first?

• A. Check the client’s calcium levels.
• B. Administer a dose of calcium gluconate.
• C. Assess the client's incision site for bleeding.
• D. Notify the healthcare provider.

Correct answer: A

Rationale: Tingling around the mouth and in the fingertips can indicate hypocalcemia, a potential complication after thyroidectomy due to accidental damage to the parathyroid glands. Checking calcium levels is crucial as it helps in diagnosing hypocalcemia accurately. Administering calcium without knowing the actual calcium levels can be dangerous. Assessing the incision site for bleeding is important but not the priority in this situation. Notifying the healthcare provider can be done after assessing and managing the immediate concern of hypocalcemia.

5. The home health nurse suspects elder abuse after observing fresh lacerations on the arms and legs of an older adult male client who lives with his daughter. Which action is most important for the nurse to take?

• A. Document the lacerations in the client's record
• B. Report findings to the supervisor for referral to adult protective services
• C. Ask the daughter who has been taking care of the client on a daily basis
• D. Apply dry dressings after cleansing the wounds

Correct answer: B

Rationale: In cases where elder abuse is suspected, the most critical action for the nurse to take is to report the findings to the supervisor for referral to adult protective services. This step is essential to protect the client from further harm and ensure their safety. Documenting the lacerations, as suggested in choice A, is important but not as urgent as ensuring immediate intervention by reporting the abuse. Asking the daughter for information, as in choice C, may not be effective if she is the abuser. Applying dressings, as in choice D, is a lower priority compared to taking action to address the suspected abuse.

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