Nursing Elites

1. 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.

2. How can a nurse make a blind 8-year-old girl admitted to the hospital more comfortable?

• A. Bring familiar toys from home, such as a bear or doll.
• B. Explain the surroundings to the child.
• C. Allow the child to explore the room.
• D. Provide audio books and music.

Correct answer: A

Rationale: The correct answer is to bring familiar toys from home, such as a bear or doll. This action provides comfort and a sense of security for the child, as it allows her to have familiar objects around her in an unfamiliar environment, which can help reduce anxiety and stress during her hospital stay.

3. A postpartum client who is Rh-negative refuses to receive RhoGAM after the delivery of an infant who is Rh-positive. Which information should the nurse provide this client?

• A. RhoGAM prevents maternal antibody formation for future Rh-positive babies.
• B. RhoGAM is not necessary unless all of her pregnancies are Rh-positive.
• C. The Rh-positive factor from the fetus threatens her blood cells.
• D. The mother should receive RhoGAM when the baby is Rh-negative.

Correct answer: A

Rationale: The correct answer is A. RhoGAM is administered to Rh-negative individuals after exposure to Rh-positive blood to prevent the development of antibodies that could harm future Rh-positive babies during subsequent pregnancies. By refusing RhoGAM after the delivery of an Rh-positive infant, the mother risks developing these antibodies, which could lead to hemolytic disease in future pregnancies with Rh-positive babies. Therefore, it is crucial for the nurse to explain to the client that receiving RhoGAM prevents the formation of maternal antibodies against Rh-positive blood, safeguarding the health of future babies. Choices B, C, and D are incorrect. Choice B is incorrect because RhoGAM is necessary after exposure to Rh-positive blood, regardless of the Rh status of future pregnancies. Choice C is incorrect as it does not accurately convey the purpose of RhoGAM administration. Choice D is incorrect because RhoGAM is specifically given after exposure to Rh-positive blood, not when the baby is Rh-negative.

4. The LPN/LVN caring for a laboring client encourages her to void at least q2h, and records each time the client empties her bladder. What is the primary reason for implementing this nursing intervention?

• A. Emptying the bladder during delivery is difficult because of the position of the presenting fetal part.
• B. An over-distended bladder could be traumatized during labor as well as prolong the progress of labor.
• C. Urine specimens for glucose and protein must be obtained at certain intervals throughout labor.
• D. Frequent voiding minimizes the need for catheterization, which increases the chance of bladder infection.

Correct answer: B

Rationale: The primary reason for encouraging the laboring client to void regularly is to prevent an over-distended bladder, which could impede the descent of the fetus, prolong labor, and be at risk for trauma during delivery. Choice A is incorrect because the difficulty in emptying the bladder during delivery is not the main reason for this nursing intervention. Choice C is incorrect as it pertains to obtaining urine specimens for glucose and protein, not the primary reason for encouraging voiding. Choice D is incorrect because although frequent voiding can indeed minimize the need for catheterization, the primary reason is to prevent an over-distended bladder and potential complications.

5. A full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first?

• A. Suction the oral and nasal passages.
• B. Give oxygen by positive pressure.
• C. Stimulate the infant to cry.
• D. Turn the infant onto the right side.

Correct answer: A

Rationale: In a situation where an infant regurgitates and turns cyanotic, the priority action should be to clear any potential airway obstruction. Suctioning the oral and nasal passages is crucial to ensure the infant's airway is clear and allow for proper breathing. This intervention takes precedence over providing oxygen, stimulating the infant to cry, or repositioning the infant.

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