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: A. Within 72 hours of delivery B. Within 1 week of delivery C. Within 2 weeks of delivery D.… Read More »
After the physician performs an amniotomy, the nurse’s first action should be to assess the: A. Degree of cervical dilation B. Fetal heart tones C. Client’s vital signs D. Client’s level of discomfort Correct Answer: B. Fetal heart tones When the membranes rupture, there is often a transient drop… Read More »
A client is admitted to the labor and delivery unit. The nurse performs a vaginal exam and determines that the client’s cervix is 5 cm dilated with 75% effacement. Based on the nurse’s assessment the client is in which phase of labor? A. Active B. Latent C. Transition D. Early … Read More »
The elderly client is admitted to the emergency room. Which symptom is the client with a fractured hip most likely to exhibit? A. Pain B. Misalignment C. Cool extremity D. Absence of pedal pulses Correct Answer: B. Misalignment The client with a hip fracture will most likely have a… Read More »
A 2-year-old is admitted for repair of a fractured femur and is placed in Bryant’s traction. Which finding by the nurse indicates that the traction is working properly? A. The infant no longer complains of pain. B. The buttocks are 15° off the bed. C. The legs are suspended in the traction.… Read More »
A client with a fractured hip has been placed in Buck’s traction. Which statement is true regarding balanced skeletal traction? Balanced skeletal traction: A. Utilizes a Steinman pin B. Requires that both legs be secured C. Utilizes Kirschner wires D. Is used primarily to heal the fractured hips … Read More »
A client has had a unilateral adrenalectomy to remove a tumor. To prevent complications, the most important measurement in the immediate postoperative period for the nurse to take is: A. Blood pressure B. Temperature C. Output D. Specific gravity Correct Answer: A. Blood pressure Blood pressure is the best… Read More »
The nurse is assessing the client with a total knee replacement 2 hours postoperative. Which information requires notification of the doctor? A. Bleeding on the dressing is 3cm in diameter. B. The client has a temperature of 100.6°F (38.1°C). C. The client’s hematocrit is 26%. D. The urinary output has been… Read More »
An elderly client with an abdominal surgery is admitted to the unit following surgery. In anticipation of complications of anesthesia and narcotic administration, the nurse should: A. Administer oxygen via nasal cannula B. Have narcan (naloxone) available C. Prepare to administer blood products D. Prepare to do cardio resuscitation … Read More »
A client with Addison’s disease has been admitted with a history of nausea and vomiting for the past 3 days. The client is receiving IV glucocorticoids (Solu-Medrol). Which of the following interventions would the nurse implement? A. Daily weights B. Intake/output measurements C. Sodium and potassium levels monitored D. Glucometer readings… Read More »