Nursing Elites

1. A pregnant client receives Rho(D) immune globulin after an amniocentesis. The day following, she reports a temperature of 99.8°F (37.67°C). Which action should the nurse implement?

• A. Schedule a visit with the healthcare provider today.
• B. Verify the compatibility of the administered Rho(D) immune globulin.
• C. Encourage the client to increase her intake of oral fluids.
• D. Instruct the client to maintain bedrest for 24 hours.

Correct answer: C

Rationale: A mild increase in temperature post-amniocentesis is common, and encouraging the client to increase oral fluid intake is the appropriate action. Increasing fluid intake can help reduce mild fever, promote recovery, and prevent dehydration. It is important for the nurse to educate the client on the importance of staying hydrated to support her overall well-being during this time.

2. The client at 10 weeks' gestation is palpated with the fundus at 3 fingerbreadths above the pubic symphysis. The client reports nausea, vomiting, and scant dark brown vaginal discharge. What action should the nurse take?

• A. Collect a urine sample for urinalysis.
• B. Measure vital signs.
• C. Recommend bed rest.
• D. Obtain human chorionic gonadotropin levels.

Correct answer: D

Rationale: In a pregnant client with a fundal height greater than expected at 10 weeks and experiencing scant dark brown vaginal discharge, there is a concern for a molar pregnancy. Assessing human chorionic gonadotropin (hCG) levels is crucial in this situation to confirm or rule out this condition.

3. A child who received multiple blood transfusions after correction of a congenital heart defect is demonstrating muscular irritability and oozing blood from the surgical incision. Which serum value is most important for the nurse to obtain before reporting to the healthcare provider?

• A. CO2 combining power
• B. Calcium
• C. Sodium
• D. Chloride

Correct answer: B

Rationale: The correct answer is Calcium. In this scenario, the child is displaying symptoms of muscular irritability and oozing blood, which are indicative of hypocalcemia. Calcium levels are crucial to monitor after multiple blood transfusions to prevent complications such as hypocalcemia, which can lead to these symptoms. Therefore, obtaining a serum calcium value is essential for the nurse to assess and address the child's condition effectively. CO2 combining power, Sodium, and Chloride levels are not directly associated with the symptoms described and are not the priority in this situation.

4. When counseling a couple seeking information about conceiving, the LPN/LVN should know that ovulation usually occurs

• A. two weeks before menstruation.
• B. immediately after menstruation.
• C. immediately before menstruation.
• D. three weeks before menstruation.

Correct answer: A

Rationale: Ovulation typically occurs about 14 days before the start of the next menstrual period. This timing allows for the released egg to travel down the fallopian tube where it may be fertilized by sperm, leading to conception. Understanding the timing of ovulation is crucial for couples trying to conceive to increase their chances of success.

5. In assessing a 9-year-old boy admitted to the hospital with possible acute post-streptococcal glomerulonephritis (APSGN), what information is most significant to obtain in his history?

• A. Back pain for a few days
• B. A history of hypertension
• C. A sore throat last week
• D. Diuresis during the nights

Correct answer: C

Rationale: A recent sore throat is most significant in this case as it could indicate a preceding streptococcal infection, which is a crucial factor in diagnosing APSGN. Streptococcal infection often precedes APSGN, and recognizing this history is essential for appropriate management and treatment. Choices A, B, and D are less relevant in the context of APSGN. Back pain and diuresis are symptoms that may not directly correlate with APSGN, while a history of hypertension, although important in general health assessment, is not as specific to the current scenario compared to a recent sore throat.

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