Nokea
For each potential assessment finding, click to specify if the assessment finding is consistent with mastitis or endometritis.
- A. Foul-smelling lochia
- B. Painful, tender breast
- C. Temperature
- D. Chills
Correct Answer: B,C,D
Rationale:
The correct answer is B, C, D.
B: Painful, tender breast - This finding is consistent with mastitis, which is an infection of the breast tissue.
C: Temperature - This finding is common in both mastitis and endometritis, indicating an infection.
D: Chills - This finding is more indicative of a systemic infection, often seen in endometritis.
Explanation for incorrect choices:
A: Foul-smelling lochia - This finding is more specific to endometritis, not mastitis.
E, F, G: Since these parameters are not provided, they cannot be selected or checked.
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A nurse is teaching a client who is trying to conceive. Which of the following should the nurse instruct the client to increase in her diet to prevent a neural tube defect?
- A. Zinc
- B. Calcium
- C. Folate
- D. Iron
Correct Answer: C
Rationale: The correct answer is C: Folate. Folate is essential for preventing neural tube defects in newborns. It helps in the development of the baby's brain and spinal cord. Zinc (A) is important for overall health but not specifically for preventing neural tube defects. Calcium (B) is crucial for bone health, not neural tube development. Iron (D) is vital for preventing anemia but not directly related to neural tube defects.
Which action should the nurse take to protect the client's confidentiality?
- A. Provide a verbal report of the client's condition to the paramedic performing the transfer
- B. Ensure that the client's medical records are securely transferred with the client to the new facility
- C. Give the client a copy of their medical records to take with them
- D. Share the client's condition only with the necessary healthcare providers at the rehabilitation facility
- E. Use a secure and private communication method to discuss the client's condition with the receiving facility
Correct Answer: E
Rationale: The correct answer is E: Use a secure and private communication method to discuss the client's condition with the receiving facility. This is the best action to protect the client's confidentiality because it ensures that sensitive information is shared in a confidential and secure manner, preventing unauthorized access. Verbal reports (choice A) can be overheard, risking confidentiality. While ensuring medical records are transferred securely (choice B) is important, discussing the client's condition directly with the necessary healthcare providers (choice D) is more immediate and can prevent unnecessary exposure of sensitive information. Giving the client a copy of their medical records (choice C) can compromise confidentiality if misplaced.
Which of the following instructions should the nurse include in the teaching?
- A. Take your temperature immediately after waking and before getting out of bed.
- B. Measure your temperature in the afternoon for the most accurate reading.
- C. A rise in body temperature of at least 2°F indicates ovulation has occurred.
- D. Use a standard digital thermometer for the most precise results.
Correct Answer: A
Rationale: The correct answer is A: Take your temperature immediately after waking and before getting out of bed. This instruction is part of basal body temperature monitoring for ovulation tracking. Body temperature is lowest upon waking and increases after ovulation, so taking the temperature before getting out of bed provides the most accurate baseline measurement. Choice B is incorrect because afternoon temperatures can fluctuate due to various factors. Choice C is incorrect as a rise of at least 0.4°F, not 2°F, indicates ovulation. Choice D is incorrect because a basal body temperature thermometer is more appropriate for this purpose than a standard digital thermometer.
Which action should the nurse take?
- A. Identify possible precipitating factors related to the infection
- B. Reinforce proper hand hygiene practices among staff.
- C. Implement a protocol for timely removal of unnecessary catheters.
- D. Provide staff education on aseptic catheter insertion techniques.
- E. Conduct regular audits on catheter care compliance.
Correct Answer: E
Rationale: The correct action for the nurse to take is E: Conduct regular audits on catheter care compliance. Audits help monitor adherence to catheter care protocols, identify areas needing improvement, and ensure staff follow best practices consistently. This action promotes quality care, reduces infection risks, and enhances patient safety. Choices A, B, C, and D are important but do not directly address ongoing monitoring and assessment of compliance like regular audits do. Conducting audits is a proactive approach to continuously evaluate and improve catheter care practices, making it the most appropriate action in this scenario.
Which of the following responses should the nurse make?
- A. Tell me what concerns you about the bedpan
- B. Make sure to use nearby furniture to support yourself when walking to the bathroom.
- C. I will have the physical therapist ambulate you to the bathroom.
- D. You have to use the bedpan for your own safety.
Correct Answer: A
Rationale: The correct answer is A: "Tell me what concerns you about the bedpan." This response demonstrates active listening and empathy, allowing the nurse to understand the patient's specific worries or fears. It promotes patient-centered care by addressing the individual's needs. Other options lack this patient-centered approach: B assumes the patient can walk, C delegates without assessing the patient's concerns, and D is directive and dismissive of the patient's feelings.