Q &A Random Selection #6 Rationale

1 B: A multigravida with station at -1, contractions at 15 minutes apart with duration of 30 seconds, cervix
dilated at 3 cm, and 10% effacement. When the station is -1 or -2 and the water breaks, the risk is greater for a
prolapsed cord.

2 A: Fecal impaction. The nurse should report fecal impaction or constipation which can cause obstruction of the
bladder outlet. Bladder outlet obstruction is a common cause of urine retention in the elderly.

3 A: Capillary refill less than 3 seconds. Since the hemoglobin and hematocrit are normal for an adult female, addition
assessments should be normal. This capillary refill time is normal.

4 B: Discuss consequences of an unbalanced diet with the child. It is important to educate the preadolescent as to
appropriate diet, and the problems that might arise if diet is not adequate.

5 C: Maternal hypertension. Pregnancy induced hypertension is a common cause of late pregnancy fetal growth
retardation. Vasoconstriction reduces placental exchange of oxygen and nutrients.

6 C: level of alertness. Assessing the level of consciousness (alert vs. lethargic vs. unresponsive) will help the
provider determine the severity of the acute episode. If the client is alert, responses to questions about complaints
can be followed-up quickly.

7 D: Assertion of control. Negativity is a normal behavior in toddlers. The nurse must be aware that this behavior is an
important sign of the child''s progress from dependency to autonomy and independence.

8 B: Sputum culture. The sputum culture is the most accurate method for determining the presence of active TB.

9 A: Rh negative mother with Rh positive baby. An Rh- mother who delivers an Rh+ baby may develop antibodies to
the fetal red cells to which she may be exposed during pregnancy or at placental separation. If the Coombs test is
negative, no sensitization has occurred. The For which of the following mother-baby pairs should the nurse review the
Coomb''s'' test in preparation for administering Rho(D) immune globulin is given to block antibody formation in the
mother.

10 A: "Spiritual healing is emphasized and the mind contributes to the cure." For the Christian Scientist, a mind cure
uses spiritual healing methods. For the believer, medical treatments may interfere with drawing closer to God.

11 A: The mother feels calmer and talks to the baby while nursing. Early evaluation of successful breastfeeding can
be measured by the client''s voiced confidence and satisfaction with the infant.

12 A: pulse oximetry of 85%. An oxygen saturation of 88% or less indicates hypoxemia and requires the nurse''s
immediate attention.

13 C: varicella. Varicella (chicken pox) and influenza are viral illnesses that have been identified as increasing the risk
for Reye''s syndrome. Use of aspirin is contraindicated for children with these infections.

14 C: Assess the family''s patterns for dealing with death. When a new problem is identified, it is important for the
nurse to collect accurate assessment data. This is crucial to ensure that the client and their family''s needs are
adequately identified in order to select the best nursing care approaches.

15 C: Assist her to position the newborn at the breast. While all of the responses are helpful in teaching, the priority is
placing the infant to breast as soon after birth as possible to establish contact and allow the newborn to begin to suck.

16 B: The rise in reported cases of positive HIV infections. Between 1985 and 2002 there has been a significant
increase in the reported cases of TB. The increase was most evident in cities with a high incidence of positive HIV
infection. Positive HIV infection currently is the greatest known risk factor for reactivating latent TB infections.

17 B: irrigate it as ordered with normal saline. Nasogastric tubes are only irrigated with normal saline to maintain
patency.

18 A: Acute tuberculosis with a productive cough of discolored sputum for over three months. The client being
admitted has the classic findings of pulmonary tuberculosis. Of the available choices, the client in option A would be
the most appropriate roommate. It is acceptable to put clients with similar diagnoses in the same room when no other
alternative exists. Clients are considered contagious until the cough is eliminated with medications, which initially is a
combination of 4 simultaneous drugs.

19 A: MMR. Medical management of Kawasaki involves administration of immunoglobulins. Measles, mumps, rubella
(MMR) is alive virus vaccine. Following administration of immunoglobulins, live vaccines should be held due to
possible interference with the body''s ability to form antibodies.
20 A: Describe the health conditions of populations. Community health focuses upon aggregate population care.

21 B: Rude. Native Americans consider direct eye contact to be impolite or aggressive among strangers.

22 D: 95% of SIDS cases occur before 6 months of age. Peak age of SIDS occurrence is 2 to 4 months and 95% of
cases occur by 6 months of age. It is the leading cause of death in infants 1 month to 1 year of age.

23 A: the airway to become narrow and obstructs airflow." Asthma is defined as airway obstruction or a narrowing
that is characterized by bronchial irritability after exposure to various stimuli.

24 B: An imbalance between red cell destruction and production. Anemia results when the rate of red cell destruction
exceeds the rate of production through stimulated erythropoiesis in bone marrow (red cell life span shortened from
120 days to 12-20 days).

25 A: tachypnea. Stimulation of respiratory center leads to hyperventilation, thus decreasing CO2 levels which
causes respiratory alkalosis.

26 D: eating peanuts. Asphyxiation due to foreign materials in the respiratory tract is the leading cause of death in
children younger than 6 years of age.

27 C: "All layers of the skin were destroyed in the burn." A third degree burn is a full thickness injury to dermis,
epidermis and subcutaneous tissue.

28 C: The child with Cystic Fibrosis needs a well balanced diet that is high in protein and calories. Fat does not need
to be restricted.

29 A: the skin. A characteristic sign of rubeola is Koplik spots (small red spots with a bluish white center). These are
found on the buccal mucosa about 2 days before and after the onset of the measles rash.
30 C: The specific gravity value is high, indicating dehydration. Poor skin turgor (tenting of the skin) is consistent with
this problem.

31 C: sodium. The client with Meniere''s disease has an alteration in the balance of the fluid in the inner ear (end
olymph). A low sodium diet will aid in reducing the fluid. Sodium restriction is also ordered as adjunct to diuretic
therapy.

32 D: This client has an actual complication. The others present with findings of potential complications.

33 A: Complaints of numbness and tingling in feet. A child who has unusual neurologic signs or symptoms,
neuropathy, footdrop, or anemia that cannot be attributed to other causes may be suffering from lead poisoning. This
most often occurs when a child ingests or inhales paint chips from lead-based paint or dust from remodeling in older
buildings.

34 A: This is the correct definition of incidence of the disease.

35 B: Activity intolerance related to oxygen supply and demand imbalance. This is the primary problem due to
decreased cardiac output related to heart failure. There is a reduction of oxygen, leading to findings of dyspnea and
fatigue.

36 D: Jitteriness at 24-48 hours. Withdrawal signs may not be evident for 1-2 days after birth. Irritability and poor
feeding also are evident.

37 C: Remain alert at all times and leave if cues suggest the home is not safe. No person or equipment can
guarantee nurses'' safety, although the risk of violence can be minimized. Before making initial visits, review referral
information carefully and have a plan to communicate with agency staff. Schedule appointments with clients. When
driving into an area for the first time, note potential hazards and sources of assistance. Become acquainted with
neighbors. Be alert and confident while parking the car, walking to the client''s door, making the visit, walking back to
the car, and driving away. LISTEN to clients. If they tell you to leave, do so.

38 B: scuba diving. The nurse would strongly emphasize the need for clients with history of spontaneous
pneumothorax problems to avoid high altitudes, flying in unpressurized aircraft and scuba diving. The negative
pressures could cause the lung to collapse again.

39 B: breathe once every 5 compressions. For a 5 year-old, the nurse should give 1 breath for every 5 compressions.

40 C: Cranial facial abnormalities are noted. Characteristic facial abnormalities are seen in the newborn with fetal
alcohol syndrome.