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A 10-day postpartum breast-feeding client telephones the postpartum unit reporting a reddened, painful breast and elevated temperature. Based on assessment of the client's complaints, which action should the nurse tell the client to do?
- A. Breast-feed only with the unaffected breast.
- B. Stop breast-feeding because you probably have an infection.
- C. Notify your health care provider because you may need medication.
- D. Continue breast-feeding since this is a normal response in breast-feeding mothers.
Correct Answer: C
Rationale: Based on the signs and symptoms presented by the client (particularly the elevated temperature), the primary health care provider needs to be notified because an antibiotic that is tolerated by the infant, as well as the mother, may be prescribed. The mother should continue to nurse on both breasts, but should start the infant on the unaffected breast while the affected breast lets down.
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The nurse is caring for a client with a history of peripheral artery disease. Which of the following interventions is most appropriate?
- A. Keep the legs elevated above heart level.
- B. Encourage prolonged standing.
- C. Apply warm compresses to the legs.
- D. Promote regular walking.
Correct Answer: D
Rationale: Regular walking promotes collateral circulation in peripheral artery disease, improving blood flow.
A client receiving a blood transfusion begins to have chills and headache within the first 15 minutes of the transfusion. The nurse should first:
- A. Administer acetaminophen.
- B. Take the client's blood pressure.
- C. Discontinue the transfusion.
- D. Check the infusion rate of the blood.
Correct Answer: C
Rationale: Chills and headache suggest a transfusion reaction, requiring immediate discontinuation of the transfusion to prevent further complications.
The nurse is teaching a client about the use of a transdermal nicotine patch for smoking cessation. Which instruction is correct?
- A. Apply it to the same site daily
- B. Remove it at night
- C. Keep it on during showers
- D. Apply it to the face
Correct Answer: B
Rationale: Removing the nicotine patch at night reduces the risk of side effects like insomnia and allows a nicotine-free period.
Bacterial conjunctivitis has affected several children at a local day care center. A nurse should advise which measure to minimize the risk of infection?
- A. Close the day care center for 1 week to control the outbreak.
- B. Restrict the infected children from returning for 48 hours after treatment.
- C. Perform thorough hand washing before and after touching any child in the day care center.
- D. Set up a conference with the parents of each child to explain the situation carefully.
Correct Answer: C
Rationale: Thorough hand washing is the most effective measure to prevent the spread of bacterial conjunctivitis.
A client with a history of chronic kidney disease is prescribed darbepoetin alfa (Aranesp). The nurse should monitor the client for which of the following side effects?
- A. Hypotension.
- B. Hypertension.
- C. Hypoglycemia.
- D. Weight loss.
Correct Answer: B
Rationale: Darbepoetin alfa can cause hypertension due to increased red blood cell production, requiring monitoring.