Which vaccinations are indicated for the postpartum client if she does not have immunity? (Select all that apply.)
a. Pertussis
b. Rubella
c. Diphtheria, tetanus (Tdap)
d. RhoGAM
ANS: A, B, C
If a client who has delivered does not have evidence of immunity, CDC recommendations advise that pertussis, rubella, and Tdap should be administered. RhoGAM is required if there is evidence of sensitization in response to Rh factor identification based on maternal and fetal blood results.
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An insulin-dependent diabetic patient is on a clear liquid diet. Which of the following trays would be appropriate to give to the patient after his lunchtime dose of insulin?
A) Diet gelatin and hot tea with sugar substitute B) Broth and diet ginger ale C) Gelatin and apple juice D) Sugar-free Popsicle and diet soda
In hyperosmolar hyperglycemic syndrome, the laboratory results are similar to those of diabetic ketoacidosis, with three major exceptions. What differences would you expect to see in patients with hyperosmolar hyperglycemic syndrome?
a. Lower serum glucose, lower osmolality, and greater ketosis b. Lower serum glucose, lower osmolality, and milder ketosis c. Higher serum glucose, higher osmolality, and greater ketosis d. Higher serum glucose, higher osmolality, and no ketosis
During a performance evaluation, the staff nurse tells the nurse manager, "I'm not the only one who takes a long lunch break, so I shouldn't be penalized for doing that." The nurse manager understands that the staff nurse's behavior is that of:
a. An exploder b. A sniper c. An unresponsive person d. A complainer
A client says to the nurse, "You are the best nurse I've ever met. I want you to remember me." What is an appropriate response by the nurse?
a. "Thank you. I think you are special too." b. "I suspect you want something from me. What is it?" c. "You probably say that to all your nurses." d. "Are you thinking of suicide?"