A postpartum client with a history of gestational diabetes expresses concern about managing blood sugar levels while breastfeeding. What nursing intervention should be prioritized to address the client's concerns?
- A. Educating the client about the importance of balanced nutrition and frequent monitoring of blood glucose levels
- B. Recommending insulin supplementation to maintain target blood sugar levels
- C. Encouraging the client to avoid breastfeeding to prevent fluctuations in blood sugar levels
- D. Referring the client to a dietitian for a specialized postpartum meal plan
Correct Answer: A
Rationale: Educating the client about the importance of balanced nutrition and frequent monitoring of blood glucose levels should be prioritized to address the client's concerns about managing blood sugar levels while breastfeeding. This intervention helps empower the client to make informed choices about her diet and monitor her blood sugar levels effectively. By focusing on balanced nutrition and regular blood glucose monitoring, the client can better manage her blood sugar levels during the postpartum period and while breastfeeding, reducing the risk of complications associated with gestational diabetes. It also promotes overall health and well-being for both the mother and the baby.
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A patient with osteoarthritis of the hip undergoes surgical intervention with a total hip arthroplasty (THA). Which postoperative complication should the healthcare team monitor for in the immediate postoperative period?
- A. Deep vein thrombosis (DVT)
- B. Delayed wound healing
- C. Pulmonary embolism
- D. Prosthetic joint infection
Correct Answer: A
Rationale: Following total hip arthroplasty (THA), patients are at an increased risk of developing deep vein thrombosis (DVT) due to factors such as immobility, surgery-related vascular damage, and hypercoagulability. DVT refers to the formation of blood clots in the deep veins, typically in the lower extremities. These clots can break loose and travel to the lungs, causing a potentially life-threatening condition called pulmonary embolism (PE). Therefore, monitoring for signs and symptoms of DVT is crucial in the immediate postoperative period to promptly detect and prevent the development of complications such as PE. Common signs of DVT include leg swelling, pain, warmth, and redness. Additionally, healthcare providers may employ preventive measures such as early ambulation, compression stockings, and anticoagulant therapy to reduce the risk of DVT post-THA surgery.
Which nursing intervention constitutes false imprisonment?
- A. A client is hospitalized as an involuntary admission and attempts to leave the unit. The nurse calls the security team per hospital protocol. They prevent the client from leaving.
- B. A psychotic client is admitted as an involuntary client and runs out of the psychiatric unit. The nurse runs after the client and succeeds in talking the client into returning to the unit.
- C. The client has been "pesky," seeking the attention of nurses in the nurses' station much of the day.
- D. The client is confused, combative, and insists that no one can stop him from leaving. The nurse restrains the client without a physician's order, then seeks the order.
Correct Answer: D
Rationale: False imprisonment occurs when a client is physically restrained or confined without legal justification. In this scenario, the nurse restraining the confused and combative client without a physician's order constitutes false imprisonment. Restraints should only be used when necessary to ensure the safety of the client or others, and a physician's order is required to authorize their use. In this case, the nurse acted without proper authorization, making it a violation of the client's rights and false imprisonment. It is essential to follow proper protocols and obtain necessary orders before restraining a client.
A nurse is caring for a patient who is experiencing end-of-life symptoms. What action by the nurse demonstrates palliative care principles?
- A. Focusing solely on physical comfort and pain management
- B. Encouraging the patient to make decisions about life-sustaining treatments
- C. Providing emotional support and addressing psychosocial needs
- D. Withholding information about the patient's prognosis to avoid distress
Correct Answer: C
Rationale: Providing emotional support and addressing psychosocial needs demonstrates palliative care principles when caring for a patient experiencing end-of-life symptoms. Palliative care focuses on holistic care that encompasses physical, emotional, and spiritual support for patients and their families during times of serious illness. By addressing emotional needs and providing support, the nurse helps improve the patient's quality of life and comfort during this difficult time. This approach goes beyond just managing physical symptoms and pain, recognizing the importance of supporting the patient's overall well-being. Encouraging the patient to make decisions about life-sustaining treatments is also an important aspect of palliative care, but providing emotional support and addressing psychosocial needs is crucial in palliative care practice.
Patient was visited by the anesthesiologist and explained the anesthesia for his surgery. Which of the following type of anesthesia would you expect to be ordered?
- A. Spinal
- B. Local
- C. Caudal
- D. General
Correct Answer: D
Rationale: When the anesthesiologist visits a patient to explain the anesthesia for surgery, the most likely type of anesthesia to be ordered in this scenario would be general anesthesia. General anesthesia is a state of controlled unconsciousness where the patient is completely unaware and unresponsive during the procedure. This type of anesthesia is typically used for surgeries that are more complex, lengthy, or invasive, requiring the patient to be completely still and asleep throughout the operation.
Take home medications given to Patient Lily includes digitalis therapy which was given to patient since she was pregnant. Which of the following would the nurse anticipate with patient's drug therapy?
- A. Switching to a more potent drug.
- B. Continuation of the same dosage.
- C. Need for change in medication.
- D. Addition of diuretic to the regimen.
Correct Answer: B
Rationale: Digitalis therapy, commonly prescribed for heart conditions, is known for its narrow therapeutic range and potential for toxicity. In the case of Patient Lily, who has been on digitalis therapy since she was pregnant, the nurse would anticipate the continuation of the same dosage to maintain the therapeutic effects and reduce the risks of toxicity. It is essential to monitor the patient's digitalis levels regularly and adjust the dosage if necessary based on the patient's response and any changes in their clinical status. Switching to a more potent drug, changing the medication, or adding a diuretic would not be appropriate without further assessment and consultation with the healthcare provider managing Lily's digitalis therapy.