Nokea
A client who has chosen to breastfeed tells the nurse that her nipples became very sore while she was breastfeeding her older child. Which measure will help her to avoid soreness of the nipples?
- A. Feeding the baby during the first 48 hours after delivery
- B. Breaking suction by placing a finger between the baby's mouth and the breast when she terminates the feeding
- C. Applying hot, moist soaks to the breast several times per day
- D. Wearing a support bra
Correct Answer: B
Rationale: Breaking suction gently prevents nipple trauma, reducing the risk of soreness during breastfeeding.
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A client scheduled for a carotid endarterectomy requires insertion of an intra-arterial blood pressure-monitoring device. The nurse plans to perform the Allen test. Which observation indicates patency of the ulnar artery?
- A. Blanching of the hand on compression and release of the ulnar artery
- B. Muscular twitching of the bicep muscle with use of a tourniquet at the wrist
- C. Hand turning pink after the nurse releases the pressure on the ulnar artery
- D. Flexion of the wrist when tapping the ulnar artery with a reflex hammer
Correct Answer: C
Rationale: The Allen test assesses collateral circulation. The hand turning pink after releasing ulnar artery pressure indicates patency, ensuring adequate blood flow if the radial artery is cannulated.
The nurse has orders for dopamine at 20 mcg/kg/min. The bag has 500 mg of dopamine in 500 mL. The client weighs 60 kg. What rate will the nurse set?
Correct Answer: 72 mL/hr
Rationale: Dose: 20 mcg/kg/min × 60 kg = 1200 mcg/min. Concentration: 500 mg/500 mL = 1 mg/mL = 1000 mcg/mL. Rate: 1200 mcg/min ÷ 1000 mcg/mL = 1.2 mL/min × 60 min/hr = 72 mL/hr.
The nurse is caring for a homeless client diagnosed with right-sided heart failure. The nurse anticipates that upon discharge the client will need assistance regarding medications, locating a shelter, and follow-up to ensure that the client can obtain transportation to the next appointment with the cardiologist. The nurse understands that this is an example of which content area of care management?
- A. advocacy
- B. delegation
- C. ethical practice
- D. continuity of care
- E. advance directive
Correct Answer: D
Rationale: Arranging post-discharge support for medications, shelter, and follow-up ensures continuity of care for a vulnerable client.
The nurse is delegating tasks to an experienced, unlicensed assistive personnel (UAP). Which of the following clients should the nurse delegate to the UAP?
- A. a client with multiple pressure ulcers requiring daily dressing changes
- B. a client with a permanent tracheostomy requiring daily tracheostomy care
- C. a client recovering from pneumonia with orders to ambulate in the hall BID
- D. a client who just received pain medication and needs to have her pain level assessed in 30 minutes
Correct Answer: C
Rationale: Ambulating a client is within a UAP’s scope, requiring minimal clinical judgment, unlike wound care, tracheostomy care, or pain assessment.
A client elects to have epidural anesthesia to relieve the discomfort of labor. Following the initiation of epidural anesthesia, the nurse should give priority to:
- A. Checking for cervical dilation
- B. Placing the client in a supine position
- C. Checking the client's blood pressure
- D. Obtaining a fetal heart rate
Correct Answer: C
Rationale: Epidural anesthesia can cause hypotension, making blood pressure monitoring a priority.