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The nurse is observing a staff member caring for a client who had a vaginal birth 30 minutes ago. The client is having difficulty with breastfeeding and is requesting assistance. The nurse should intervene if the staff member is observed
- A. providing supplemental formula feedings until improved breastfeeding occurs
- B. checking the newborn's position and sucking behavior during breastfeeding
- C. demonstrating to the client how to express breastmilk using the hand
- D. providing information on recognizing newborn hunger cues
Correct Answer: A
Rationale: Supplemental formula may undermine breastfeeding efforts early on. Checking position , demonstrating expression , and teaching hunger cues support breastfeeding.
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The nurse is caring for a client receiving Theodur (theophylline). Side effects associated with bronchodilators include:
- A. Irritability, rapid pulse, and palpitations
- B. Slow pulse, increased appetite, and sweating
- C. Anxiety, nausea, and increased blood pressure
- D. Drowsiness, vomiting, and decreased blood sugar
Correct Answer: A
Rationale: Theophylline can cause irritability, rapid pulse, and palpitations due to its stimulant effects. Slow pulse , drowsiness , or decreased blood sugar are not typical.
An adult is almost ready for discharge. She has a complicated care regimen to follow. When conducting client teaching, the nurse notes that the client cannot recall basic information that was discussed the day before. The client also appears distracted. When asked if she is feeling comfortable about leaving the hospital, she states, 'There's just too much to learn. I know I'm going to get home and mess something up.' The nurse realizes that the client may be experiencing:
- A. mild anxiety.
- B. moderate anxiety.
- C. severe anxiety.
- D. panic anxiety.
Correct Answer: B
Rationale: Difficulty recalling information and expressed worry about managing care suggest moderate anxiety, impairing learning but not reaching panic.
The nurse is caring for an adult male who is receiving haloperidol (Haldol). Which complaint by the client is of most concern to the nurse and should be immediately reported?
- A. I have gained so much weight in the last few months.
- B. I am having trouble getting an erection.
- C. My legs are cramping and I feel like I need to walk all the time.
- D. It's really embarrassing. I'm drooling a lot.
Correct Answer: C
Rationale: Leg cramping and restlessness suggest akathisia, a serious extrapyramidal side effect of haloperidol, requiring immediate reporting.
The health care provider prescribes phenazopyridine hydrochloride for a client with a urinary tract infection. What would the office nurse remind the client to expect while taking this medication?
- A. Constipation
- B. Difficulty sleeping
- C. Discoloration of urine
- D. Dry mouth
Correct Answer: C
Rationale: Phenazopyridine causes orange-red urine discoloration, a benign effect. Constipation , insomnia , and dry mouth are not typical.
Laboratory results
Hematocrit
Male: 42%-52%
(0.42-0.52)
Female: 37%-47%
(0.37-0.47) 29%
(0.29)
Hemoglobin
Male: 14-18 g/dL
(140-180 g/L)
Female: 12-16 g/dL
(120-160 g/L) 9.7 g/dL
97 (g/L)
The nurse is caring for a client with chronic kidney disease who is scheduled to receive recombinant human erythropoietin and iron sucrose. Which of the following actions should the nurse take?
- A. Administer erythropoietin in the client's ventrogluteal muscle.
- B. Check the client's blood pressure prior to administering erythropoietin.
- C. Contact the health care provider to clarify the prescription for iron sucrose.
- D. Hold erythropoietin and inform the health care provider of the laboratory test results.
Correct Answer: B
Rationale: Erythropoietin can increase blood pressure, so checking BP is essential. It's given IV or SC, not IM . Iron sucrose is standard , and holding erythropoietin requires lab evidence.