Nokea
A 20-year-old primipara attends a class for women who plan to breastfeed. To prepare for breastfeeding, the nurse should encourage the women to
- A. apply moisturizer to their breasts every day after bathing.
- B. expose their breasts to air every day for 20 minutes.
- C. wash their breasts with water and rub with a towel every day.
- D. massage their breasts to increase circulation twice daily.
Correct Answer: C
Rationale: prepares nipples for stretching action of sucking during breastfeeding, soap avoided to prevent drying
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The nurse is caring for a client with a history of epilepsy.
- A. Which precaution is most important for a client with epilepsy?
- B. Keep the bed in the lowest position.
- C. Restrict all visitors to reduce stress.
- D. Administer oxygen during seizures.
- E. Place a padded tongue blade at the bedside.
Correct Answer: A
Rationale: Keeping the bed in the lowest position reduces fall risk during seizures. Visitors are not restricted, oxygen is not routine, and tongue blades are contraindicated.
The nurse is caring for a client with a history of gastroesophageal reflux disease (GERD).
- A. Which instruction is most appropriate for a client with GERD?
- B. Eat large meals to reduce acid production.
- C. Lie down immediately after eating.
- D. Elevate the head of the bed during sleep.
- E. Avoid drinking water with meals.
Correct Answer: C
Rationale: Elevating the head of the bed during sleep prevents acid reflux by using gravity to keep stomach contents down. Large meals and lying down post-meal worsen reflux, and water is neutral.
A brace is ordered for a young teen with scoliosis. The nurse knows that teaching has been effective if the client makes which of the following statements?
- A. I will have my parents put bed-boards on my bed.
- B. I should decrease my caloric intake.
- C. I should only take tub baths.
- D. I can remove the brace for one hour a day.
Correct Answer: D
Rationale: should be worn at all times, except when bathing
The nurse is preparing a 56-year-old woman for a paracentesis. It is MOST important for the nurse to take which of the following actions?
- A. Keep the woman NPO 12 hours before the procedure.
- B. Have the woman void just before the procedure.
- C. Initiate a bowel preparation program 24 hours before the procedure.
- D. Place the woman supine during the procedure.
Correct Answer: B
Rationale: prevents puncture of bladder
The nurse is caring for a client in her third trimester of pregnancy. The nurse is MOST concerned by which of the following assessments?
- A. The client complains of epigastric pain.
- B. The client complains of shortness of breath.
- C. The client states she has increased rectal pressure.
- D. The client has gained of 33 pounds during her pregnancy.
Correct Answer: A
Rationale: is usually indicative of an impending convulsion