1. A pediatric client has rubeola. What kind of infection control measure should the nurse initiate?
a. Airborne precautions.
Rationale- The infection control measure that must be initiated is airborne transmission precautions because the mode of transmission for rubeola, or measles, is airborn...
1. A pediatric client has rubeola. What kind of infection control measure should the nurse
initiate?
a. Airborne precautions.
Rationale- The infection control measure that must be initiated is airborne transmission
precautions because the mode of transmission for rubeola, or measles, is airborne. This type of
transfer occurs when the pathogen is carried in dust or droplets in the air and that remains in
place for a sufficient time to infect a person exposed to this air.
Do not confuse rubeola with rubella. Rubeola (measles) requires airborne precautions,
whereas rubella requires droplet precautions.
2. The nurse is educating patient that are attending a prenatal class. Which of the
following statements should the nurse make?
a. “Amniocentesis may be used to assess for chromosomal abnormalities”
Rationale- Amniocentesis is a widely used antepartum test that may determine the gender of a
fetus, the presence of neural tube defects, chromosomal abnormalities, and fetal lung maturity.
This test also may be used therapeutically for polyhydramnios as it may remove some of the
excessive amniotic fluid volume.
3. The nurse has instructed a patient who has been diagnosed with atrial fibrillation.
Which of the following statements by the patient would require a follow-up?
a. “I should weigh myself daily at the same time”
b. “I should wear a mask when I am in public”
Rationale- These two statements indicate that the patient needs further follow-up education to
correct the misconceptions. The client does not need to weigh themselves daily (Choice B) as
that would be applicable for CHF and not for atrial fibrillation. Considering daily weight checks
in CHF is useful to detect excess fluid retention, which may precede symptoms such as shortness
of breath. Wearing a mask in public is unnecessary as an infection is not the concern here
(Choice D).
4. The nurse is educating a pregnant client who is admitted with deep vein thrombosis in
her left lower extremity. The client is at 24 weeks of gestation. The client is placed on
Low Molecular Weight Heparin (LMWH). Which of the following statements by the
client indicate that she understand the education regarding LMWH?
a. “I hate injections. I will likely switch to warfarin after delivery”
b. “There is an increased risk of fractures with long term LMWH therapy”
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c. “If I notice blisters or black, red areas at the injection site, then I will hold LMWH
and immediately contact the doctor”
Rationale- LMWH is the anticoagulant of choice during pregnancy because it does not cross the
placenta, but one may switch to warfarin in the post-partum period. While warfarin is
contraindicated during active pregnancy due to its potential to cause congenital fetal
disabilities, maternal/fetal bleeding, and miscarriages, it is considered safe in the post-partum
period. Warfarin is also safe in lactating/breastfeeding women. The client will need a minimum
of 3 to 6 months of anticoagulation and therefore will be requiring anticoagulation for a few
weeks even after delivery. Additionally, the risk of recurrent venous thromboses is high up to 6
weeks post-partum. Since the client does not like injections, oral anticoagulation with warfarin is
an option for her after delivery (Choice C).
Long-term treatment with LMWH may decrease bone mineral density (osteopenia, osteoporosis)
and increase the risk of fractures (Choice D). For those with pre-existing osteoporosis and
fracture risk, close monitoring is needed when on long-term LMWH therapy.
It is common to have some bruising and swelling at the injection site. However, the presence of
blisters and necrotic areas (blackish-red central portion) at the injection site may serve as a
warning sign of a complication known as heparin-induced-thrombocytopenia (HIT). If the
patient or the nurse notes necrotic areas at the injection site, the physician must be notified
immediately and LMWH must be discontinued (Choice E). HIT is a rare but dangerous
complication with unfractionated and low-molecular-weight heparins. The body forms
antibodies to heparin that may cross-react with platelet antigens and cause a drop in the platelets.
Despite a decline in the platelet count, HIT is associated with the formation of thromboses (deep
vein thrombosis and pulmonary embolism) because HIT antibodies disrupt and activate the
clotting system. If HIT is confirmed, heparin should never be re-initiated. Other anticoagulants,
such as argotraban or fondaparinaux, are used.
5. The occupational health nurse was called to see a construction worker who has sustained
injuries from a light bulb explosion. On assessment, the nurse notes that a piece of glass
was lodged in the worker’s eye. Initial nursing intervention should be:
a. Advise the worker to rest in a sitting position until expert care arrives.
Rationale- To prevent intraocular pressure (IOP) from increasing, the client should be advised to
stay seated, as the lying position may increase IOP and cause the glass to advance further into the
eye. The nurse should also recommend the client rest and avoid unnecessary movement until an
ophthalmologist arrives to decrease the possibility of further eye damage.
6. Place the following 7 right of medication administration in the correct order:
a. Right patient
b. Right medication
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c. Right dose
d. Right route
e. Right time
f. Right documentation
g. Right response
Rationale- First, the nurse should verify the right patient by using two patient identifiers. Next,
she should verify the correct medication on both the order and the medication label. Next, she
should verify the right dose as written in the order and check that it is an appropriate dose for the
patient. Next, the right route should be verified in the order and the nurse should check if it is
safe to administer via this route for this patient. Next, the right time should be verified; the nurse
should check that the medication is being administered at the ordered time and frequency. Next,
the right documentation; the nurse should document the administration of the medication as well
as pertinent information such as vital signs, lab values, and/or injection sites. Lastly, the nurse
should monitor the patient for the right response; ensure the expected response to the medication
is observed and that appropriate follow up monitoring is also documented.
7. While preparing to discharge a 2-year-old newly diagnosed with hypothyroidism,
you include which of the following education points in your discharge teaching?
a. “Take the thyroid medication at the same time each day”
b. “Avoid taking the thyroid medication in the evening”
Rationale- When discharging a pediatric patient who is newly diagnosed with hypothyroidism, it
is essential to educate the parents about how to administer thyroid medication. It should be taken
at the same time each day, on an empty stomach, 30 minutes before breakfast.
8. The nursing student is explaining the cause of Cushing’s disease. Which of the
following statements indicate a correct understanding of this illness?
a. Cushing’s disease is the result of the increased production of pituitary hormones.
Rationale- Cushing’s disease occurs when adrenocorticotropic hormones are over secreted by
the pituitary gland, increasing cortisol.
9. Which of the following obstetrical procedures can be used to assist the head of the
fetus during vaginal delivery?
a. Forceps assisted delivery
b. Vacuum assisted delivery
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