Nokea
A nurse is caring for a client who is postpartum and asks the nurse when her breast milk will 'come in.' Which of the following responses should the nurse make?
- A. Within 2 days.
- B. In 3 to 5 days.
- C. In about 10 days.
- D. In 6 to 8 days.
Correct Answer: B
Rationale: The correct answer is B: In 3 to 5 days. This is because breast milk typically comes in around 3 to 5 days after giving birth, as it takes time for hormonal changes to trigger milk production. Option A (Within 2 days) is too soon for most women to experience lactogenesis II. Option C (In about 10 days) and Option D (In 6 to 8 days) are both incorrect as they are outside the typical timeframe for milk production to start. It's important for the nurse to provide accurate information to the client to manage her expectations and provide proper support during this crucial time.
You may also like to solve these questions
A nurse is preparing a response protocol for botulism as a bioterrorism agent. The nurse should prepare the protocol based on which of the following information? (Select all that apply.)
- A. Botulism is acquired through direct contact with an infected person.
- B. Notify the Centers for Disease Control and Prevention (CDC) when more than three cases are confirmed.
- C. Botulism can produce paralysis within 12 to 72 hours following exposure.
- D. Vomiting and diarrhea are expected findings following exposure.
- E. Botulism is a toxin found in castor beans.
Correct Answer: C,D
Rationale: The correct answers are C and D. Choice C is correct because botulism can indeed produce paralysis within 12 to 72 hours following exposure. This is crucial information for early detection and treatment. Choice D is also correct because vomiting and diarrhea are not typical symptoms of botulism. The toxin primarily affects the nervous system, leading to symptoms such as muscle weakness and paralysis. Choices A, B, and E are incorrect. Botulism is not acquired through direct contact with an infected person (A), the CDC should be notified immediately upon suspicion of botulism, not after a certain number of cases (B), and botulism toxin is not found in castor beans (E).
A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?
- A. Handrails are present in the bathroom.
- B. Electrical cords are placed along the walls.
- C. Uses a microwave for cooking.
- D. Scatter rugs are present in the kitchen.
Correct Answer: D
Rationale: The correct answer is D: Scatter rugs are present in the kitchen. Scatter rugs can pose a safety risk for an older adult with decreased vision due to glaucoma as they increase the risk of tripping and falling. The uneven surface and lack of secure placement make scatter rugs hazardous. Handrails in the bathroom (A) enhance safety, electrical cords along the walls (B) may be a tripping hazard but can be easily addressed, and using a microwave for cooking (C) is a safe and convenient option for someone with decreased vision.
A nurse working for a home health agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address?
- A. Pruritus
- B. Swollen gums
- C. Dysphagia
- D. Urinary hesitancy
Correct Answer: C
Rationale: The correct answer is C: Dysphagia. Dysphagia, difficulty swallowing, is a priority finding in an older adult male as it can lead to aspiration and malnutrition. The nurse needs to address this promptly to prevent complications. Pruritus (choice A) is itching and can be managed. Swollen gums (choice B) may indicate dental issues but are not immediately life-threatening. Urinary hesitancy (choice D) can be indicative of a urinary problem but does not pose an immediate risk compared to dysphagia.
A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?
- A. Bradycardia
- B. Hyperglycemia
- C. Dehydration
- D. Polyphagia
Correct Answer: C
Rationale: The correct answer is C: Dehydration. In diabetes insipidus, there is a deficiency of antidiuretic hormone leading to excessive urine output, causing dehydration. Bradycardia (A) is not typically associated. Hyperglycemia (B) is seen in diabetes mellitus, not diabetes insipidus. Polyphagia (D) is excessive hunger, which is not a common symptom of diabetes insipidus.
A nurse working on a medical unit is completing the admission of a client who reports a severe allergy to penicillin. Which of the following actions should the nurse take?
- A. Remove all objects that contain latex from the client’s room.
- B. Verify the client’s medication prescriptions do not include cephalosporin.
- C. Notify dietary services to adjust the client’s diet.
- D. Have the client purchase a medication alert bracelet to wear in the hospital.
Correct Answer: B
Rationale: The correct answer is B: Verify the client’s medication prescriptions do not include cephalosporin. This is essential because cephalosporins are antibiotics that share a similar structure to penicillin and can potentially cause an allergic reaction in individuals with a penicillin allergy. By ensuring that the client's medication prescriptions do not include cephalosporin, the nurse is taking a proactive step to prevent any adverse reactions.
Removing objects containing latex (choice A) is not directly related to the client’s penicillin allergy. Notifying dietary services to adjust the client’s diet (choice C) is unnecessary as the allergy is to penicillin, not food. Having the client purchase a medication alert bracelet (choice D) is not as immediate or essential as verifying medication prescriptions.