Nokea
A client who gave birth 48 hours ago has decided to bottle-feed the infant. The nurse observes that both breasts were swollen, warm, and tender on palpation during the assessment. Which instruction should the nurse provide?
- A. Take warm showers to reduce swelling
- B. Wear a tight-fitting bra for support
- C. Apply ice to the breasts for comfort
- D. Express milk manually to relieve discomfort
Correct Answer: C
Rationale: The correct answer is to advise the client to apply ice to the breasts for comfort. Applying ice can help reduce swelling and discomfort associated with engorgement in a woman who is not breastfeeding. Expressing milk manually would stimulate further milk production, which is not desired in this case. Wearing a tight bra could increase discomfort by putting pressure on the engorged breasts. Warm showers may actually increase swelling due to the vasodilation effect of heat.
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A client with hyperthyroidism is experiencing palpitations. What intervention should the nurse implement?
- A. Encourage the client to rest and limit activity.
- B. Administer a beta-blocker to reduce heart rate.
- C. Encourage the client to drink cool fluids.
- D. Provide the client with a cool environment.
Correct Answer: B
Rationale: In clients with hyperthyroidism experiencing palpitations, administering a beta-blocker is the appropriate intervention. Beta-blockers help reduce heart rate and control symptoms in hyperthyroidism. Encouraging rest (Choice A) may be helpful but does not directly address the palpitations. Drinking cool fluids (Choice C) and providing a cool environment (Choice D) are more focused on temperature regulation and comfort, which are not the primary interventions for palpitations in hyperthyroidism.
A client with cirrhosis is admitted with ascites and peripheral edema. Which intervention should the nurse implement first?
- A. Elevate the legs to reduce swelling.
- B. Restrict fluids to reduce fluid overload.
- C. Administer furosemide to reduce fluid overload.
- D. Monitor the client's intake and output.
Correct Answer: C
Rationale: Administering a diuretic like furosemide is the priority intervention for a client with cirrhosis, ascites, and peripheral edema. Furosemide helps reduce fluid overload by promoting diuresis. Elevating the legs may provide some symptomatic relief but does not address the underlying issue of fluid overload. Restricting fluids is not appropriate initially as the client needs proper hydration while managing fluid balance. Monitoring intake and output is important but not the first action to address the immediate fluid overload in this client.
A client has been receiving hydromorphone every six hours for four days. What assessment should the nurse prioritize?
- A. Increase the dosage of the medication.
- B. Auscultate bowel sounds.
- C. Monitor the client's blood pressure.
- D. Check the client's respiratory rate.
Correct Answer: B
Rationale: The correct answer is B. Hydromorphone can cause constipation, a common side effect of opioids. Therefore, it is crucial to auscultate bowel sounds to monitor for signs of decreased gastrointestinal motility. Monitoring blood pressure (choice C) and respiratory rate (choice D) are important but not the priority in this scenario as constipation is a common issue with opioid use. Increasing the dosage of the medication (choice A) is not appropriate without assessing the client's bowel function first.
The nurse receives a report on an older adult client with middle stage dementia. What information suggests the nurse should do immediate follow-up rather than delegate care to the nursing assistant?
- A. Has had a change in respiratory rate with an increase of 2 breaths
- B. Has had a change in heart rate with an increase of 10 beats
- C. Was minimally responsive to voice and touch
- D. Has had a blood pressure change with a drop of 8 mmHg systolic
Correct Answer: C
Rationale: A change in responsiveness, as indicated by being minimally responsive to voice and touch, suggests a potential acute issue that requires immediate nursing assessment and intervention rather than delegation. Changes in vital signs (choices A, B, D) can be important but do not always indicate an immediate need for nursing intervention compared to a change in responsiveness.
A client tells the nurse about working out with a personal trainer and swimming three times a week in an effort to lose weight and sleep better. The client states that it still takes hours to fall asleep at night. Which action should the nurse implement?
- A. Advise the client to reduce exercise intensity
- B. Ask the client for a description of the exercise schedule that is being followed
- C. Encourage the client to try relaxation techniques before bed
- D. Suggest avoiding water-based exercise before bed
Correct Answer: B
Rationale: Asking the client for a description of the exercise schedule being followed is the most appropriate action for the nurse to take in this scenario. Understanding the timing and intensity of the client's exercise routine can help identify if the activity is contributing to sleep disturbances. Exercise too close to bedtime can cause difficulty falling asleep. Choices A, C, and D do not directly address the need to assess the exercise schedule and may not provide the necessary information to identify the potential cause of the client's sleep issue.