a nurse is providing information for a woman who is 36 weeks pregnant and who has hepatitis b which of the following statements from the client indica

NCLEX-RN

NCLEX RN Prioritization Questions

1. A pregnant woman who is 36 weeks' pregnant and has hepatitis B is being informed by a nurse. Which of the following statements from the client indicates understanding of this condition?

A. Now I know my baby will need a cesarean section.
B. My baby will need two shots soon after birth.
C. I will not be able to breastfeed.
D. My baby's father does not need testing; I know I am the one with hepatitis.

Correct answer: B

Rationale: The correct answer is 'My baby will need two shots soon after birth.' A baby born to a mother with hepatitis B should receive two injections soon after birth to reduce the risk of contracting the disease. Within the first 12 hours post-birth, the baby should receive the first hepatitis B vaccine and hepatitis B immune globulin (HBIG) for additional protection. Option A is incorrect because the need for a cesarean section is not directly related to the mother's hepatitis B status. Option C is incorrect as breastfeeding can be safe if managed properly. Option D is incorrect as the baby's father should also be tested for hepatitis B to prevent transmission to the newborn.

2. Which of the following is TRUE about shock?

A. A patient with severe shock does not always have an abnormally low blood pressure.
B. Confusion and deteriorating mentation are indicative of hypotensive shock.
C. Patients with compensated shock may not be able to maintain a normal blood pressure.
D. A normal blood pressure does not imply that the patient is stable.

Correct answer: B

Rationale: Confusion and deteriorating mentation are indeed indicative of hypotensive shock. It is important to note that a patient with hypotensive shock will likely exhibit deteriorating mental status. Choice A is incorrect because a patient in severe shock may not always have an abnormally low blood pressure, making it an unreliable indicator of shock severity. Choice C is incorrect because patients with compensated shock may present with normal blood pressure but still have inadequate tissue perfusion. Choice D is incorrect because a normal blood pressure does not guarantee the patient's stability, especially in cases of shock where tissue perfusion may be compromised despite normal blood pressure readings.

3. The nurse is caring for a 13-year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate post-operative period?

A. Raise the head of the bed at least 30 degrees
B. Encourage ambulation within 24 hours
C. Maintain in a flat position, logrolling as needed
D. Encourage leg contraction and relaxation after 48 hours

Correct answer: C

Rationale: In the immediate post-operative period following spinal fusion for scoliosis in a 13-year-old, it is important to maintain the patient in a flat position and perform logrolling as needed. This helps prevent injury to the surgical site and ensures proper spinal alignment. Raising the head of the bed at least 30 degrees is contraindicated as it can put strain on the surgical site. Encouraging ambulation within 24 hours may be appropriate in the recovery process but not in the immediate post-operative period. Encouraging leg contraction and relaxation after 48 hours may also be part of the rehabilitation process but is not a priority in the immediate post-operative period.

4. Which fact about diabetes is true?

A. Only children get type 1 diabetes.
B. Only adults get type 2 diabetes.
C. Children and adults can have type 1 diabetes.
D. Both A and B

Correct answer: C

Rationale: The correct answer is that children and adults can have type 1 diabetes. Although type 1 diabetes is sometimes known as 'childhood diabetes,' it can affect individuals of any age. Type 1 diabetes is not limited to children. While type 2 diabetes is often associated with adults, children can also develop it, especially due to factors like obesity. Choices A and B are incorrect because diabetes is not exclusive to either children or adults; both types of diabetes can affect individuals across different age groups.

5. A patient is admitted with active tuberculosis (TB). The nurse should question a healthcare provider's order to discontinue airborne precautions unless which assessment finding is documented?

A. Chest x-ray shows no upper lobe infiltrates.
B. TB medications have been taken for 6 months.
C. Mantoux testing shows an induration of 10 mm.
D. Three sputum smears for acid-fast bacilli are negative.

Correct answer: D

Rationale: The correct answer is D: Three sputum smears for acid-fast bacilli are negative. Negative sputum smears indicate that Mycobacterium tuberculosis is not present in the sputum, and the patient cannot transmit the bacteria by the airborne route. This finding is crucial for discontinuing airborne precautions. Choice A is incorrect because chest x-rays do not determine the presence of active TB for transmission precautions. Choice B is not directly related to the infectiousness of TB; completing a 6-month course of medication is important for treatment but does not confirm the absence of active disease or infectiousness. Choice C is not relevant to assessing infectiousness; Mantoux testing measures exposure to TB but does not confirm the absence of active infection or infectiousness.