Nursing Elites

1. A postpartum client with AB negative blood whose newborn is B positive requires what intervention?

• A. Administer Rh immune globulin within 72 hours of delivery
• B. Administer Rh immune globulin at the 6-week postpartum visit
• C. No Rh immune globulin is needed since this is the second pregnancy
• D. Both mother and baby need Rh immune globulin

Correct answer: A

Rationale: The correct intervention is to administer Rh immune globulin within 72 hours of delivery. This is essential to prevent the mother from forming antibodies against Rh-positive blood, which could cause complications in future pregnancies. Choice B is incorrect as the administration should be immediate postpartum. Choice C is incorrect as Rh immune globulin is needed for each Rh-incompatible pregnancy. Choice D is incorrect as only the mother, who is Rh-negative, needs Rh immune globulin.

2. A client with a new ileostomy is receiving discharge instructions from a nurse. Which statement indicates the client understands the teaching?

• A. I will make sure my medications are enteric-coated.
• B. My stoma will drain liquid continuously.
• C. I will change my pouch system every two weeks.
• D. My stoma size will stay the same after it heals.

Correct answer: B

Rationale: The correct answer is B. Ileostomy stomas typically drain liquid continuously, unlike colostomies. This continuous drainage is a key characteristic that clients should understand postoperatively. Choice A is incorrect because ensuring medications are enteric-coated is not directly related to understanding ileostomy care. Choice C is incorrect as changing the pouch system every two weeks is not a general rule and may vary depending on the individual's needs. Choice D is incorrect because the stoma size can change during the healing process and clients should be informed about this possibility.

3. A nurse is preparing to administer a dose of ampicillin. Which of the following actions should the nurse take?

• A. Administer it with food
• B. Check for penicillin allergy
• C. Monitor liver function
• D. Administer it intramuscularly

Correct answer: B

Rationale: The correct answer is to 'Check for penicillin allergy.' Before administering ampicillin, it is crucial to assess the patient for any history of penicillin allergy. This is essential to prevent an adverse allergic reaction, as ampicillin belongs to the penicillin class of antibiotics. Administering ampicillin with food (Choice A) is not a standard requirement and does not impact its effectiveness. Monitoring liver function (Choice C) is not directly related to the immediate pre-administration assessment for ampicillin. Administering ampicillin intramuscularly (Choice D) is not typically the route of administration for this antibiotic, as it is usually given intravenously or orally.

4. A nurse is assessing a client with chronic kidney disease. Which laboratory value would indicate the need for hemodialysis?

• A. Glomerular filtration rate (GFR) of 14 mL/min
• B. BUN 16 mg/dL
• C. Serum magnesium 1.8 mg/dL
• D. Serum phosphorus 4.0 mg/dL

Correct answer: A

Rationale: A GFR of 14 mL/min indicates significant kidney damage and a severe decrease in kidney function. This level of GFR typically indicates the need for hemodialysis to help the kidneys perform their function adequately. BUN, serum magnesium, and serum phosphorus levels are important in assessing kidney function and managing chronic kidney disease but do not specifically indicate the need for hemodialysis. Therefore, choices B, C, and D are incorrect.

5. When teaching a client about the use of trazodone, what should be included?

• A. It can cause sedation
• B. It is a stimulant
• C. It has no side effects
• D. It should be taken with food

Correct answer: A

Rationale: The correct answer is A. Trazodone can cause sedation, so clients should be cautioned about activities requiring alertness, like driving. Choice B is incorrect because trazodone is not a stimulant; it is actually a sedating antidepressant. Choice C is incorrect as all medications have potential side effects. Choice D is not specifically indicated for trazodone; the client should follow the prescribing healthcare provider's instructions regarding food intake.

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