Nokea
A client who is three days postpartum and is bottle-feeding her infant calls the nurse at the gynecology clinic with complaints of breast engorgement. What instruction should the nurse provide?
- A. reduce fluid intake to 1,500 ml/day
- B. take a warm shower twice a day
- C. apply a tight binder around her breasts
- D. come in to see the physician immediately as this is abnormal
Correct Answer: C
Rationale: A tight binder helps relieve breast engorgement by suppressing lactation in bottle-feeding mothers, a normal postpartum occurrence.
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Someone sees a nursing assistant yell at an elderly client and throw his lunch tray off the table. The nursing assistant could likely be charged with
- A. negligence.
- B. assault.
- C. malpractice.
- D. battery.
Correct Answer: B
Rationale: Yelling and throwing a tray constitute assault (threatening behavior causing fear of harm). Battery involves physical contact, negligence involves failure to act, and malpractice applies to professional errors.
The nurse is assessing a client following a coronary artery bypass graft (CABG). The nurse should give priority to reporting:
- A. Chest drainage of 150 mL in the past hour
- B. Confusion and restlessness
- C. Pallor and coolness of skin
- D. Urinary output of 40 mL per hour
Correct Answer: B
Rationale: Confusion and restlessness may indicate cerebral hypoxia or other serious complications post-CABG, requiring immediate reporting.
A client is admitted for suspected bladder cancer. Which one of the following factors is most significant in the client's diagnosis?
- A. Smoking a pack of cigarettes a day for 30 years
- B. Use of nonsteroidal anti-inflammatories
- C. Eating foods with preservatives
- D. Past employment involving asbestos
Correct Answer: A
Rationale: Long-term smoking is a major risk factor for bladder cancer due to carcinogenic chemicals in tobacco being excreted in urine, irritating the bladder.
A client has been diagnosed with immune thrombocytic purpura (ITP). Which of the following signs and symptoms indicate increased thrombocytopenia? Select all that apply.
- A. Frequent nosebleeds
- B. Petechiae and increased bruising
- C. Temporary changes in vision
- D. Numbness and tingling in distal limbs
- E. Confusion
Correct Answer: A,B
Rationale: ITP causes low platelets, leading to nosebleeds (A) and petechiae/bruising (B). Vision changes (C), numbness (D), and confusion (E) are not typical.
The nurse receives an order for blood cultures and sensitivity for a client. Which statement is correct concerning this test?
- A. Preliminary test results are available 36 hours to allow the organisms time to grow.
- B. Growth and identification of the organism often takes 48 to 72 hours to complete.
- C. If the client has IV antibiotics infusing, stop the infusion before drawing blood cultures.
- D. If catheter sepsis is suspected, culturing the catheter tip is more accurate for identification.
Correct Answer: B
Rationale: Blood culture results typically take 48–72 hours for organism identification. Stopping antibiotics or culturing catheter tips is not standard practice.