Nokea
The nurse is providing postpartum teaching for a non-nursing mother. Which of the client's statements indicates the need for additional teaching?
- A. I'm wearing a support bra.
- B. I'm expressing milk from my breast.
- C. I'm drinking four glasses of fluid during a 24-hour period
- D. While I'm in the shower, I'll keep the water from running over my breasts
Correct Answer: B
Rationale: Non-nursing mothers should avoid expressing milk, as it stimulates further production. Support bras, adequate fluids, and avoiding breast stimulation are correct practices.
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The nurse is caring for a client whose peritoneal dialysis is beginning to exhibit insufficient outflow. What actions should the nurse perform initially? Select all that apply.
- A. Check the client for abdominal distention and constipation
- B. Examine the catheter for kinks and obstructions
- C. Contact the client's health care provider
- D. Place the client in a side-lying position
- E. Flush the tubing with dialysate
Correct Answer: A,B,D
Rationale: Checking for distention/constipation (A), examining for catheter issues (B), and repositioning to a side-lying position (D) address common causes of outflow issues non-invasively.
The nurse is talking with the parent of a pediatric client who had a cast applied to the right arm 30 minutes ago. Which of the following statements by the parent would require follow-up?
- A. I understand that my child may feel tingling or burning underneath the cast for the first few days.
- B. I can use a hair dryer to blow cool air underneath the cast if my child experiences itching.
- C. I will call the clinic if my child experiences pain that is not relieved with medication.
- D. I should keep my child's arm elevated while resting for the first few days.
Correct Answer: A
Rationale: Tingling or burning may indicate neurovascular compromise or pressure on nerves, requiring immediate evaluation, not dismissal as normal.
The nurse is teaching a group of adults about modifiable cardiac risk factors. Which of the following should the nurse focus on first?
- A. Weight reduction
- B. Stress management
- C. Physical exercise
- D. Smoking cessation
Correct Answer: D
Rationale: Smoking cessation. Stopping smoking is the priority for clients at risk for cardiac disease, because of its effects of reducing oxygenation and constricting blood vessels.
The nurse is preparing to administer the fourth dose of IV vancomycin to a client. Which set of laboratory values would alert the nurse to hold the vancomycin and notify the health care provider?
- A. Vancomycin trough 10 mg/L (6.9 umol/L), creatinine 1.1 mg/dL (97.2 umol/L), BUN 6 mg/dL (2.1 mmol/L)
- B. Vancomycin trough 14 mg/L (9.7 umol/L), creatinine 1.2 mg/dL (106.1 umol/L), BUN 10 mg/dL (3.6 mmol/L)
- C. Vancomycin trough 18 mg/L (12.4 umol/L), creatinine 0.6 mg/dL (53 umol/L), BUN 18 mg/dL (6.4 mmol/L)
- D. Vancomycin trough 23 mg/L (15.9 umol/L), creatinine 1.5 mg/dL (132.6 umol/L), BUN 24 mg/dL (8.6 mmol/L)
Correct Answer: D
Rationale: A vancomycin trough of 23 mg/L is above the therapeutic range (10-20 mg/L), indicating potential toxicity. Elevated creatinine (1.5 mg/dL) suggests renal impairment, which increases the risk of vancomycin accumulation and nephrotoxicity.
The nurse is caring for a client who is experiencing status epilepticus and does not have a peripheral venous access device. Which of the following actions should the nurse take first?
- A. Administer rectal diazepam.
- B. Transport the client for a CT scan.
- C. Obtain a blood specimen for complete blood count.
- D. Check the client for neck stiffness and Brudzinski sign.
Correct Answer: A
Rationale: Rectal diazepam is a first-line treatment for status epilepticus when IV access is unavailable, as it rapidly terminates seizures to prevent brain damage.