Nokea
The nurse is reinforcing teaching with a client in the postpartum period who is breastfeeding and has breast engorgement. Which of the following information should the nurse include?
- A. Apply ice packs to your breasts for 15 to 20 minutes before breastfeeding
- B. Allow your baby to nurse for at least 10 to 15 minutes on each breast
- C. Temporarily decrease the frequency of your breastfeeding
- D. Avoid taking NSAIDs for discomfort while breastfeeding
Correct Answer: B
Rationale: Nursing for 10-15 minutes per breast relieves engorgement by emptying milk ducts. Ice packs are used after, not before, feeding; decreasing frequency worsens engorgement; and NSAIDs are safe for breastfeeding.
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The nurse is assessing a client who had a left arm cast applied four hours ago. Which finding indicates that the client may have circulatory impairment?
- A. The client's nail beds blanch when the nurse applies pressure; color returns in two seconds.
- B. The client's fingers on the left hand are cold to the touch.
- C. The client complains of pain at the fracture site.
- D. The client is unable to move the fingers on the left hand.
Correct Answer: B
Rationale: Cold fingers suggest impaired circulation in the casted arm, indicating potential compartment syndrome or vascular compromise, requiring immediate evaluation. Normal blanching, fracture pain, or immobility are less specific.
A client is admitted with diabetic ketoacidosis (DKA). Which laboratory finding requires immediate intervention by the nurse?
- A. Blood glucose of 450 mg/dL
- B. Potassium level of 4.0 mEq/L
- C. PaO2 of 92 mmHg
- D. HCT of 60
Correct Answer: C
Rationale: This high hematocrit is indicative of severe dehydration which requires priority attention in diabetic ketoacidosis. Without sufficient hydration, all systems of the body are at risk for hypoxia from a lack of or sluggish circulation.
A nurse observes a family member administer a rectal suppository by having the client lie on the left side for the administration. The family member pushed the suppository until the finger went up to the second knuckle. After 10 minutes the client was told by the family member to turn to the right side and the client did this. What is the appropriate comment for the nurse to make?
- A. Why don't we now have the client turn back to the left side.
- B. That was done correctly. Did you have any problems with the insertion?
- C. Let's check to see if the suppository is in far enough.
- D. Did you feel any stool in the intestinal tract?
Correct Answer: B
Rationale: Left side-lying position is the optimal position for the client receiving rectal medications. Due to the position of the descending colon, left side-lying allows the medication to be inserted and move along the natural curve of the intestine and facilitates retention of the medication.
The nurse is caring for a client with an exacerbation of asthma following a viral respiratory illness. When collecting data, the nurse expects to find which clinical characteristics of a severe asthma exacerbation? Select all that apply.
- A. Accessory muscle use
- B. Chest tightness
- C. High-pitched expiratory wheeze
- D. Prolonged inspiratory phase
- E. Tachypnea
Correct Answer: A,B,C,E
Rationale: Severe asthma exacerbations cause accessory muscle use, chest tightness, high-pitched wheezing, and tachypnea due to airway obstruction. Prolonged expiration, not inspiration, is typical as air is trapped.
An adult diagnosed with celiac disease 3 weeks ago was placed on a gluten-free diet. The client returns for ambulatory care follow-up, reports continuation of symptoms, and does not seem to be responding to therapy. Which is the best response by the nurse?
- A. It should take about 6-8 weeks before your symptoms improve
- B. Tell me what you had to eat yesterday
- C. We will refer you to the dietitian
- D. You must not be following your diet
Correct Answer: B
Rationale: Asking about recent food intake helps identify unintentional gluten exposure, common in new celiac diagnoses. Assuming 6-8 weeks, immediate referral, or blaming non-compliance may overlook dietary errors or other causes.