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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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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.
A patients family is exhibiting increasingly impaired coping as the patients condition deteriorates. The nurse asks the family to state the biggest concern from their perspective.What is the most important rationale for this question?
- A. The question indicates active listening on the part of the nurse.
- B. The question is used as a way to validate the familys knowledge.
- C. The question clarifies the nurses understanding of current family needs.
- D. The question promotes problem definition, which helps define the degree of family understanding.
Correct Answer: C
Rationale: The correct answer is C because asking the family to state their biggest concern clarifies the nurse's understanding of the current family needs. This step allows the nurse to assess the specific areas where the family may require support or assistance, leading to more tailored interventions. By identifying the primary concern, the nurse can better address the family's emotional, informational, or practical needs.
Choice A is incorrect because the question is not solely about active listening; it serves a deeper purpose of assessment. Choice B is incorrect as the question goes beyond validating knowledge to understanding emotional and practical needs. Choice D is incorrect because the question focuses on identifying concerns rather than defining the degree of understanding.
The urgent care center protocol for tick bites includes the following actions. Which action will the nurse take first when caring for a patient with a tick bite?
- A. Use tweezers to remove any remaining ticks.
- B. Check the vital signs, including temperature.
- C. Give doxycycline (Vibramycin) 100 mg orally.
- D. Obtain information about recent outdoor activities.
Correct Answer: A
Rationale: The correct answer is A: Use tweezers to remove any remaining ticks. The first step is to remove the tick to prevent further transmission of any potential pathogens. This is crucial in preventing tick-borne illnesses. Checking vital signs (B) can be done after the tick is removed. Administering doxycycline (C) should be based on guidelines and individual factors. Obtaining information about recent outdoor activities (D) is important but not the immediate priority.
The family of a critically ill patient has asked to discuss organ donation with the patient’s nurse. When preparing to answer the family’s questions, th e nurse understands which concern(s) most often influence a family’s decision to donate? (Select all that apply.)
- A. Donor disfigurement influences on funeral care
- B. Fear of inferior medical care provided to donor
- C. Age and location of all possible organ recipients
- D. Concern that donated organs will not be used
Correct Answer: A
Rationale: Rationale for Correct Answer A: Donor disfigurement influences on funeral care. Families often consider the impact of organ donation on the appearance of their loved one during funeral arrangements. This concern can significantly influence their decision to donate.
Incorrect Answers:
B: Fear of inferior medical care provided to donor. This is not a common concern as medical care for donors is typically of high quality.
C: Age and location of all possible organ recipients. While important, this is not a primary concern for families when deciding on organ donation.
D: Concern that donated organs will not be used. Families are generally more concerned about the impact on their loved one's appearance post-donation rather than the utilization of organs.
The nurse is preparing to administer atropine, an anticholinergic, to a client scheduled for a cholecystectomy. The client asks the nurse to explain the reason for the prescribed medication. What response is best for the nurse to provide?
- A. Provide a more rapid induction of anesthesia.
- B. Induce relaxation before induction of anesthesia.
- C. Decrease the risk of bradycardia during surgery.
- D. Minimize the amount of analgesia needed postoperatively.
Correct Answer: C
Rationale: The correct answer is C: Decrease the risk of bradycardia during surgery.
Rationale:
1. Atropine is an anticholinergic medication that works by blocking the parasympathetic nervous system.
2. During surgery, the parasympathetic stimulation can lead to bradycardia (slow heart rate).
3. By administering atropine, the nurse can counteract the bradycardic effects and maintain a normal heart rate during the procedure.
4. Options A, B, and D are incorrect as atropine is not used for inducing anesthesia, relaxation, or minimizing postoperative analgesia.