Nokea
Following an emergency Cesarean delivery, the nurse encourages the new mother to breastfeed her newborn. The client asks why she should breastfeed now. Which information should the nurse provide?
- A. Stimulate contraction of the uterus.
- B. Initiate the lactation process.
- C. Facilitate maternal-infant bonding.
- D. Prevent neonatal hypoglycemia.
Correct Answer: A
Rationale: The correct answer is A because breastfeeding helps stimulate the uterus to contract, which reduces the risk of postpartum hemorrhage in the mother. When the baby suckles at the breast, it triggers the release of oxytocin, a hormone that causes the uterus to contract. This contraction helps the uterus to return to its pre-pregnancy size and shape, promoting faster healing and reducing bleeding.
Choice B is incorrect because lactation initiation is a separate process that involves hormonal changes and milk production, which may not occur immediately after delivery. Choice C is incorrect as bonding can occur through various interactions beyond breastfeeding. Choice D is incorrect as neonatal hypoglycemia is primarily prevented by ensuring the baby receives adequate nutrition, which can also be achieved through other feeding methods besides breastfeeding.
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The nurse returns from the cardiac catheterization laboratory with a patient following insertion of a pulmonary artery catheter and assists in transferring th e patient from the stretcher to the bed. Prior to obtaining a cardiac output, which action is m ost important for the nurse to complete?
- A. Document a pulmonary artery catheter occlusion press ure.
- B. Zero reference the transducer system at the phlebostatic axis.
- C. Inflate the pulmonary artery catheter balloon with 1 m L air.
- D. Inject 10 mL of 0.9% normal saline into the proximal port.
Correct Answer: B
Rationale: The correct answer is B: Zero reference the transducer system at the phlebostatic axis. This is the most important action before obtaining a cardiac output because zero referencing ensures accurate pressure readings. The phlebostatic axis is the level of the atria when the patient is supine, and zeroing at this point minimizes errors in pressure measurements.
Choice A is incorrect because documenting a pulmonary artery catheter occlusion pressure is not the priority at this stage. Choice C is incorrect as inflating the balloon with air should be done after zero referencing. Choice D is incorrect as injecting normal saline into the port is not necessary before zero referencing.
The family of a critically ill patient has asked to discuss organ donation with the patient’s nurse. When preparing to answer the family’s questions, th e nurse understands which concern(s) most often influence a family’s decision to donate? (Select all that apply.)
- A. Donor disfigurement influences on funeral care
- B. Fear of inferior medical care provided to donor
- C. Age and location of all possible organ recipients
- D. Concern that donated organs will not be used
Correct Answer: A
Rationale: Rationale for Correct Answer A: Donor disfigurement influences on funeral care. Families often consider the impact of organ donation on the appearance of their loved one during funeral arrangements. This concern can significantly influence their decision to donate.
Incorrect Answers:
B: Fear of inferior medical care provided to donor. This is not a common concern as medical care for donors is typically of high quality.
C: Age and location of all possible organ recipients. While important, this is not a primary concern for families when deciding on organ donation.
D: Concern that donated organs will not be used. Families are generally more concerned about the impact on their loved one's appearance post-donation rather than the utilization of organs.
A triage nurse in a busy emergency department (ED) assesses a patient who complains of 7/10 abdominal pain and states, 'I had a temperature of 103.9°F (39.9°C) at home.' The nurse’s first action should be to:
- A. Assess the patient’s current vital signs.
- B. Give acetaminophen (Tylenol) per agency protocol.
- C. Ask the patient to provide clean-catch urine for urinalysis.
- D. Tell the patient that it will be 1 to 2 hours before being seen by the doctor.
Correct Answer: A
Rationale: The correct answer is A: Assess the patient's current vital signs. The nurse's first action should be to gather objective data to assess the patient's condition and determine the urgency of the situation. Vital signs, including temperature, heart rate, blood pressure, and respiratory rate, provide crucial information for the initial assessment. This will help the nurse identify any signs of sepsis, shock, or other serious conditions that require immediate intervention.
The other choices are incorrect because:
B: Giving acetaminophen without assessing the patient's vital signs and determining the cause of the symptoms could mask important clinical information and delay appropriate treatment.
C: While obtaining a urine sample may be necessary later to rule out a urinary tract infection, it is not the most immediate priority in this case.
D: Delaying the patient's assessment and care based on estimated wait times is not appropriate when the patient presents with potentially serious symptoms. Immediate evaluation is required in this scenario.
A patient in the ICU is complaining that he is not sleeping well at night because of anxiety. Which of the following would be the most helpful intervention for the nurse to make?
- A. Provide the patient with a bath immediately following his first 90-minute REM sleep cycle.
- B. Increase the patients pain medication.
- C. Provide the patient with 5 minutes of effleurage and then minimize disruptions.
- D. Monitor the patients brain waves by polysomnography to determine his sleep pattern.
Correct Answer: C
Rationale: Rationale:
C: Providing the patient with 5 minutes of effleurage (gentle massage) and minimizing disruptions is the most helpful intervention. Effleurage can help reduce anxiety and promote relaxation, improving sleep quality. Minimizing disruptions creates a conducive environment for sleep.
A: Providing a bath after REM sleep may disrupt the patient's sleep cycle, worsening anxiety.
B: Increasing pain medication may not address the root cause of anxiety and could lead to dependency or side effects.
D: Monitoring brain waves with polysomnography is an invasive procedure not typically indicated for managing anxiety-related sleep issues.
A Muslim patient has been admitted to the critical care unit with complications after childbirth. Based on the Synergy Model, which nurse would be the most inappropriate to assign to care for this patient?
- A. New graduate female nurse
- B. Most experienced female nurse
- C. New graduate male nurse
- D. Female nurse with postpartum experience
Correct Answer: C
Rationale: Step-by-step rationale:
1. The Synergy Model emphasizes matching nurse competencies with patient needs.
2. A male nurse may not be culturally appropriate for a Muslim female patient due to religious beliefs.
3. Gender segregation is important in Islamic culture, especially concerning intimate care.
4. Therefore, assigning a new graduate male nurse to care for a Muslim female patient in critical condition is the most inappropriate choice.
Summary:
- Choice A is incorrect because being a new graduate does not impact cultural competence.
- Choice B is incorrect as experience does not necessarily make a nurse the best fit for a specific patient.
- Choice D is incorrect as postpartum experience is relevant, but cultural considerations are more critical in this scenario.