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Following an emergency Cesarean delivery, the nurse encourages the new mother to breastfeed her newborn. The client asks why she should breastfeed now. Which information should the nurse provide?
- A. Stimulate contraction of the uterus.
- B. Initiate the lactation process.
- C. Facilitate maternal-infant bonding.
- D. Prevent neonatal hypoglycemia.
Correct Answer: A
Rationale: The correct answer is A because breastfeeding helps stimulate the uterus to contract, which reduces the risk of postpartum hemorrhage in the mother. When the baby suckles at the breast, it triggers the release of oxytocin, a hormone that causes the uterus to contract. This contraction helps the uterus to return to its pre-pregnancy size and shape, promoting faster healing and reducing bleeding.
Choice B is incorrect because lactation initiation is a separate process that involves hormonal changes and milk production, which may not occur immediately after delivery. Choice C is incorrect as bonding can occur through various interactions beyond breastfeeding. Choice D is incorrect as neonatal hypoglycemia is primarily prevented by ensuring the baby receives adequate nutrition, which can also be achieved through other feeding methods besides breastfeeding.
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The nurse is preparing to provide postmortem care for a patient who has just died. Which action should the nurse take first?
- A. Close the patient’s eyes and place a pillow under the head.
- B. Wash the patient’s body and apply a clean gown.
- C. Remove all medical equipment and tubes.
- D. Confirm that a death certificate has been signed.
Correct Answer: A
Rationale: Rationale:
A: Closing the patient's eyes and placing a pillow under the head is the first step in postmortem care to maintain dignity and prevent airway occlusion.
B: Washing the body and changing clothes can be done later and is not the priority.
C: Removing medical equipment can wait until after ensuring the patient's comfort.
D: Confirming the death certificate is important but not the immediate first step in postmortem care.
Which statement about resuscitation is true?
- A. Family members should never be present during resusc itation.
- B. It is not necessary for a physician to write “do not resu scitate” orders in the chart if a patient has a healthcare surrogate.
- C. “Slow codes” are ethical and should be considered in f utile situations if advanced directives are not available.
- D. Withholding “extraordinary” resuscitation is legal anda ebtirhbi.ccoaml /tiefs ts pecified in advance directives and physician orders.
Correct Answer: D
Rationale: The correct answer is D because it accurately states that withholding "extraordinary" resuscitation is legal and should be based on specified criteria in advance directives and physician orders. This is in line with medical ethics and patient autonomy.
A is incorrect because family presence during resuscitation can be beneficial for emotional support and decision-making. B is incorrect as it is still necessary for a physician to document "do not resuscitate" orders even with a healthcare surrogate. C is incorrect as "slow codes" are not ethical and go against the principle of beneficence.
A 100-kg patient gets hemodialysis 3 days a week. In planning the care for this patient, the nurse recommends
- A. a diet of 2500 to 3500 kcal per day.
- B. protein intake of less than 50 grams per day.
- C. potassium intake of 10 mEq per day.
- D. fluid intake of less than 500 mL per day.
Correct Answer: A
Rationale: The correct answer is A: a diet of 2500 to 3500 kcal per day. During hemodialysis, the patient loses nutrients and energy, so a high-calorie diet is necessary to maintain proper nutrition and energy levels. 2500-3500 kcal/day is a suitable range for a 100-kg patient.
Choice B is incorrect because protein intake should be adequate to prevent malnutrition in hemodialysis patients, typically 1.2g/kg body weight/day. Choice C is incorrect as potassium intake should be restricted in hemodialysis patients due to impaired kidney function. Choice D is incorrect because fluid intake should be individualized based on the patient's fluid status and should not be limited to less than 500 mL per day.
During the primary assessment of a victim of a motor vehicle collision, the nurse determines that the patient is breathing and has an unobstructed airway. Which action should the nurse take next?
- A. Palpate extremities for bilateral pulses.
- B. Observe the patient’s respiratory effort.
- C. Check the patient’s level of consciousness.
- D. Examine the patient for any external bleeding.
Correct Answer: B
Rationale: Rationale: The correct action is to observe the patient's respiratory effort next. This step ensures that the patient's breathing remains stable and adequate. If respiratory effort is compromised, immediate intervention is required. Checking for bilateral pulses (A) is important but comes after ensuring respiratory status. Checking level of consciousness (C) is also crucial but not as immediate as monitoring breathing. Examining for external bleeding (D) is important but not the priority when airway and breathing are already determined to be clear.
The nurse cares for a patient with lung cancer in a home hospice program. Which action by the nurse is most appropriate?
- A. Discuss cancer risk factors and appropriate lifestyle modifications.
- B. Encourage the patient to discuss past life events and their meaning.
- C. Teach the patient about the purpose of chemotherapy and radiation.
- D. Accomplish a thorough head-to-toe assessment several times a week.
Correct Answer: B
Rationale: The correct answer is B because in a home hospice program, it is essential for the nurse to provide holistic care that includes addressing the patient's emotional and psychological needs. Encouraging the patient to discuss past life events and their meaning can help them process emotions, find closure, and improve their quality of life. This approach aligns with the principles of palliative care, which focus on enhancing comfort and well-being.
Choice A is incorrect because discussing cancer risk factors and lifestyle modifications may not be relevant or beneficial for a patient in a hospice program. Choice C is incorrect because chemotherapy and radiation are typically not part of hospice care, which focuses on comfort rather than curative treatments. Choice D is incorrect because a thorough head-to-toe assessment multiple times a week may not be necessary or appropriate for a patient in a hospice program.