a nurse is caring for a 3 day old infant who needs an exchange transfusion which of the following statements is appropriate for teaching the childs pa
Logo

Nursing Elites

NCLEX-RN

Health Promotion and Maintenance NCLEX RN Questions

1. A nurse is caring for a 3-day old infant who needs an exchange transfusion. Which of the following statements is appropriate for teaching the child's parents about this procedure?

Correct answer: B

Rationale: : An exchange transfusion is a method of controlling high bilirubin levels in infants when traditional phototherapy is unsuccessful. During an exchange transfusion, the physician removes 5-10 cc of blood and then replaces it with donor blood. The parents of this infant should know that the procedure is always performed by a physician and will take approximately 1 � hours to complete.

2. The chain of infection includes the ________________.

Correct answer: A

Rationale: The chain, or cycle, of infection includes the germ (microorganism), agent, reservoir, exit portal, mode of transmission, entry port, and susceptible host. This sequence describes how infections are passed from one person to another. Choice B is incorrect because it refers to types of immunity, not components of the chain of infection. Choice C is also incorrect as it lists terms unrelated to the chain of infection. Choice D is incorrect as it describes transmission types, not components of the chain of infection. Understanding the chain of infection is crucial in preventing the spread of infections by breaking one or more links in the chain, such as interrupting the mode of transmission through proper hand hygiene.

3. Upon admission to the stroke care unit of a rehabilitation center, what is the primary action of the nurse?

Correct answer: C

Rationale: When a client is admitted to a stroke care unit in a rehabilitation center, the nurse's initial priority is to assess the client. This assessment includes identifying relevant health history data that may impact the client's care. By recognizing the client's current needs and limitations, the nurse can develop a comprehensive understanding of the client's condition. This information is crucial for generating a nursing diagnosis and establishing appropriate care outcomes. While collecting and organizing documents for the medical record, preparing identification bracelets, and securing valuables are important tasks, they are not the primary actions that directly influence the client's immediate care upon admission.

4. Mr. G has been admitted to the hospital with a head injury after a 12-foot fall. Which of the following nursing interventions is most appropriate when monitoring intracranial pressure?

Correct answer: D

Rationale: Administering corticosteroids as ordered is appropriate when monitoring intracranial pressure in clients at risk of increased pressure to reduce brain tissue swelling. Elevating the head of the bed helps in managing intracranial pressure by promoting venous drainage. Administering hypertonic solutions is used to reduce brain edema and control intracranial pressure. Increasing the client's core body temperature is not recommended as it can exacerbate brain injury. Corticosteroids are not routinely used for all head injuries but may be indicated in specific cases, such as certain types of brain injuries where swelling needs to be controlled.

5. Examples of preservation of self-integrity include all of the following except:

Correct answer: C

Rationale: Preservation of self-integrity involves actions that support the nurse's well-being and ethical standards. Using assistive equipment to move bariatric clients and practicing hand hygiene and personal protective equipment are essential aspects of maintaining physical health and safety, contributing to self-care. Participating in wellness programs further enhances self-care by promoting overall well-being. However, accepting the challenge of caring for clients with oppositional beliefs or practices can be emotionally taxing and may compromise a nurse's self-integrity if it leads to significant moral distress or ethical conflicts. In such situations, it is important for nurses to prioritize their well-being and ethical values by seeking alternative solutions or support.

Similar Questions

An 18-year-old male patient informs the nurse that he isn't sure if he is homosexual because he is attracted to both genders. The nurse establishes a trusting relationship with the patient by saying:
A client in labor has an electronic fetal monitor attached to the abdomen, and the nurse notes that the baby's heart rate slows down during each contraction, returning to normal limits only after the contraction is complete. Which type of fetal heart rate change does this pattern describe?
A client asks a nurse, 'Do you think I should move back home after this procedure?' and the nurse responds by saying, 'Do you think you should move back home?' What type of therapeutic communication is the nurse representing?
A client diagnosed with schizophrenia is slow to respond and appears to be listening to unseen others. Which medication should a nurse expect a physician to order to address this type of symptom?
Thrombolytic therapy is frequently used in the treatment of suspected stroke. Which of the following is a significant complication associated with thrombolytic therapy?

Access More Features

NCLEX RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses