the nurse is caring for a 13 year old following spinal fusion for scoliosis which of the following interventions is appropriate in the immediate post

NCLEX-RN

NCLEX RN Practice Questions Exam Cram

1. The nurse is caring for a 13-year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate post-operative period?

A. Raise the head of the bed at least 30 degrees
B. Encourage ambulation within 24 hours
C. Maintain in a flat position, logrolling as needed
D. Encourage leg contraction and relaxation after 48 hours

Correct answer: C

Rationale: In the immediate post-operative period following spinal fusion for scoliosis in a 13-year-old, it is important to maintain the patient in a flat position and perform logrolling as needed. This helps prevent injury to the surgical site and ensures proper spinal alignment. Raising the head of the bed at least 30 degrees is contraindicated as it can put strain on the surgical site. Encouraging ambulation within 24 hours may be appropriate in the recovery process but not in the immediate post-operative period. Encouraging leg contraction and relaxation after 48 hours may also be part of the rehabilitation process but is not a priority in the immediate post-operative period.

2. Rhogam is most often used to treat mothers that have a infant.

A. RH positive, RH positive
B. RH positive, RH negative
C. RH negative, RH positive
D. RH negative, RH negative

Correct answer: C

Rationale: Rhogam is administered to RH-negative mothers who have an RH-positive infant to prevent the development of anti-RH antibodies in the mother's system. Choice A (RH positive, RH positive) is incorrect because Rhogam is not used when both mother and infant are RH positive. Choice B (RH positive, RH negative) is incorrect because Rhogam is used when the mother is RH negative, not RH positive. Choice D (RH negative, RH negative) is incorrect as Rhogam is not typically needed if both mother and infant are RH negative.

3. Administration of hepatitis B vaccine to a healthy 18-year-old patient has been effective when a specimen of the patient's blood reveals

A. HBsAg.
B. anti-HBs
C. anti-HBc IgG
D. anti-HBc IgM.

Correct answer: B

Rationale: The correct answer is 'anti-HBs'. The presence of surface antibody to HBV (anti-HBs) indicates a successful response to the hepatitis B vaccine. Anti-HBs is a marker of immunity and protection against hepatitis B infection. Choices A, C, and D are incorrect because: A) HBsAg indicates current infection with hepatitis B virus, C) anti-HBc IgG suggests past infection or immunity, and D) anti-HBc IgM is a marker of acute hepatitis B infection.

4. A patient with bacterial pneumonia has rhonchi and thick sputum. What is the nurse's most appropriate action to promote airway clearance?

A. Assist the patient to splint the chest when coughing.
B. Teach the patient about the need for fluid intake.
C. Encourage the patient to wear the nasal oxygen cannula.
D. Instruct the patient on the pursed lip breathing technique.

Correct answer: A

Rationale: Assisting the patient to splint the chest when coughing is the most appropriate action to promote airway clearance in a patient with bacterial pneumonia, rhonchi, and thick sputum. Splinting the chest helps reduce pain during coughing and increases the effectiveness of clearing secretions. Teaching the patient about the need for fluid intake is important as it helps liquefy secretions, aiding in easier clearance. Encouraging the patient to wear a nasal oxygen cannula may improve gas exchange but does not directly promote airway clearance. Instructing the patient on the pursed lip breathing technique is beneficial for improving gas exchange in patients with COPD but does not directly aid in airway clearance in a patient with bacterial pneumonia and thick sputum.

5. What is the most frequent cause for suicide in adolescents?

A. Progressive failure to adapt
B. Feelings of anger or hostility
C. Reunion wish or fantasy
D. Feelings of alienation or isolation

Correct answer: D

Rationale: Feelings of alienation or isolation are the most frequent cause for suicide in adolescents. Adolescents may experience a gradual isolation leading to a loss of meaningful social contacts, which can be self-imposed or result from an inability to express feelings. During this developmental stage, achieving a sense of identity and peer acceptance is crucial. Choices A, B, and C are incorrect: Progressive failure to adapt, feelings of anger or hostility, and reunion wish or fantasy are not typically identified as the primary cause of suicide in adolescents.