Nursing Elites

1. The licensed practical nurse assigned to the postpartum unit is preparing to administer Rhogam to a postpartum client. Which woman is not a candidate for RhoGam?

• A. A gravida IV para 3 that is Rh negative with an Rh-positive baby
• B. A gravida I para 1 that is Rh negative with an Rh-positive baby
• C. A gravida II para 0 that is Rh negative admitted after a stillbirth delivery
• D. A gravida IV para 2 that is Rh negative with an Rh-negative baby

Correct answer: D

Rationale: The mothers in answers A, B, and C all require RhoGam as they are Rh negative with an Rh-positive baby or have experienced a stillbirth delivery, making them candidates for RhoGam injection. The mother in answer D is the only one who does not require Rhogam because she is Rh negative with an Rh-negative baby, eliminating the need for RhoGam administration.

2. A nurse provides information about feeding to the mother of a 6-month-old infant. Which statement by the mother indicates an understanding of the information?

• A. Meats are really important for iron, and I should start feeding meats to my infant right away.
• B. Egg white should not be given to my infant because of the risk for an allergy.
• C. I can mix the food in my infant's bottle if he won't eat it.
• D. Fluoride supplementation is not necessary until permanent teeth come in.

Correct answer: B

Rationale: The correct answer is B: 'Egg white should not be given to my infant because of the risk for an allergy.' Egg white, even in small quantities, is not recommended for infants until the end of the first year of life due to its common allergenic potential. Choice A is incorrect because while meats are important for iron, they are not typically introduced to infants until around 6-8 months. Choice C is incorrect because food should never be mixed with formula in the bottle as it may lead to feeding difficulties and inaccurate monitoring of intake. Choice D is incorrect because fluoride supplementation may be required around 6 months depending on the infant's fluoride intake from water. Introducing solid foods like rice cereal, fruits, or vegetables is usually done around 5-6 months, following healthcare provider recommendations.

3. A 50-milliliter (ml) bolus of normal saline fluid is ordered by the physician. The physician wants it to infuse in 30 minutes. The nurse should set the pump rate at:

• A. 100 ml per hour for one hour.
• B. 60 ml per hour for one-half hour
• C. 120 ml per hour for one hour.
• D. 50 ml per hour for one hour.

Correct answer: A

Rationale: To infuse a 50 ml bolus in 30 minutes, the rate should be calculated as follows: 50 ml / 30 min = 100 ml per hour. Therefore, the correct answer is to set the pump rate at 100 ml per hour for one hour. Choice A is the correct rate based on the calculation. Choices B, C, and D all provide incorrect rates that do not match the physician's order. Choice B would only deliver 30 ml in 30 minutes, not the ordered 50 ml. Choice C would deliver 120 ml in one hour, which is 20 ml more than ordered. Choice D would only provide 25 ml over 30 minutes, not the full 50 ml prescribed.

4. A client with schizophrenia says, 'I'm away for the day ... but don't think we should play "? or do we have feet of clay?' Which alteration in the client's speech does the nurse document?

• A. Neologism
• B. Word salad
• C. Clang association
• D. Associative looseness

Correct answer: D

Rationale: The correct answer is 'Associative looseness.' In the provided speech, the client shows associative looseness by making loose connections between phrases without a clear logical link. Clang association involves rhyming words without regard for their meaning. Neologism refers to made-up words with specific meaning to the client, and word salad is a jumble of words that lack coherence either to the listener or the client. Understanding these speech patterns associated with schizophrenia is crucial in identifying the specific alteration in speech displayed by the client in this scenario.

5. Ashley and her boyfriend Chris, both 19 years old, are transported to the Emergency Department after being involved in a motorcycle accident. Chris is badly hurt, but Ashley has no apparent injuries, though she appears confused and has trouble focusing on what is going on around her. She complains of dizziness and nausea. Her pulse is rapid, and she is hyperventilating. The nurse should assess Ashley's level of anxiety as:

• A. mild.
• B. moderate.
• C. severe.
• D. panic.

Correct answer: C

Rationale: Explanation: Ashley is displaying symptoms of severe anxiety, including confusion, trouble focusing, dizziness, nausea, rapid pulse, and hyperventilation. These somatic symptoms, along with changes in vital signs, indicate severe anxiety. In severe anxiety, individuals are unable to solve problems and have a poor grasp of their environment. On the other hand, mild anxiety may lead to mild discomfort or even enhanced performance, while moderate anxiety results in difficulty grasping information and minor changes in vital signs. Panic, the most severe level of anxiety, involves markedly disturbed behavior and a potential loss of touch with reality. Therefore, based on Ashley's symptoms, her anxiety level should be assessed as severe.

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