Nokea
On the first postpartum day, the nurse is caring for a primiparous client who has recently emigrated from Japan to the United States and speaks only a little English. The nurse observes that the client has been bottle-feeding her neonate on occasion, but most of the neonatal care is being performed by the client's mother-in-law. Which of the following actions would be most appropriate?
- A. Notify the social worker because bonding may be affected.
- B. Document the unusual maternal behavior in the client's chart.
- C. Determine whether this is a cultural practice for the client and her family.
- D. Obtain an order to make a home visit after the client's discharge.
Correct Answer: C
Rationale: Assessing whether the mother-in-law's involvement is a cultural practice respects the client's background and avoids misjudging normal family dynamics.
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The nurse assists the physician in inserting a temporary pacemaker into the client. After the procedure, the nurse should verify that which of the following has been documented?
- A. The client's cardiovascular status.
- B. The client's emotional state.
- C. The type of sedation used.
- D. Pacemaker rate, type, and settings.
Correct Answer: D
Rationale: Documenting the pacemaker rate, type, and settings is critical to ensure proper function and patient safety post-procedure. While cardiovascular status and sedation are important, the pacemaker specifics are the priority for verification.
An adult client has bacterial conjunctivitis. What should the nurse teach him to do? Select all that apply.
- A. Use warm saline soaks four times per day to remove crusting.
- B. Apply topical antibiotic without touching the tip of the tube to his eye.
- C. Wash his hands after touching his eyes.
- D. Avoid touching his eyes.
- E. Observe isolation procedures and confine himself to his bedroom until the redness in the eye disappears.
Correct Answer: A,B,C,D
Rationale: Warm saline soaks, careful antibiotic application, hand washing, and avoiding eye contact prevent spread and promote healing. Isolation is unnecessary unless specified.
The nurse is caring for a client with a history of deep vein thrombosis who is prescribed enoxaparin (Lovenox). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild bruising.
- B. Bleeding gums.
- C. Headache.
- D. Nausea.
Correct Answer: B
Rationale: Bleeding gums indicate a potential bleeding complication with enoxaparin, requiring immediate reporting.
A client with a history of ulcerative colitis is prescribed sulfasalazine (Azulfidine). The nurse should instruct the client to:
- A. Take the medication with meals.
- B. Avoid sun exposure.
- C. Stop the medication if diarrhea resolves.
- D. Take the medication on an empty stomach.
Correct Answer: B
Rationale: Sulfasalazine can cause photosensitivity, so clients should avoid sun exposure.
The nurse is caring for a client who has just received a diagnosis of terminal cancer. The client says, 'I don't want to tell my family yet.' Which of the following responses by the nurse is most appropriate?
- A. You should tell them soon so they can support you.'
- B. I respect your decision. Let me know how I can help you.'
- C. Your family needs to know so they can prepare.'
- D. I'll talk to your family for you if you'd like.'
Correct Answer: B
Rationale: Respecting the client's autonomy while offering support is the most appropriate response, honoring their decision about disclosure.