Nokea
The nurse is teaching a client who is preparing to breast-feed. What is the best approach to promote successful breast-feeding?
- A. Give her a pamphlet on breast-feeding
- B. Discuss the advantages of breast milk
- C. Assist her to position the newborn at the breast
- D. Tell her to always breast-feed when the infant cries
Correct Answer: C
Rationale: Assist her to position the newborn at the breast. While all of the responses are helpful in teaching, the priority is placing the infant to breast as soon after birth as possible to establish contact and allow the newborn to begin to suck.
You may also like to solve these questions
The nurse enters an adult's room to premedicate for surgery. The client says, 'You know, nurse, that form I signed said something about a nephrectomy. What does that mean?' How should the nurse respond initially?
- A. What did your surgeon explain to you about your operation?'
- B. Don't worry about the technical terms. We'll take good care of you.'
- C. I think you're just nervous about the surgery. This injection will make you feel calmer.'
- D. It is a kidney operation.'
Correct Answer: A
Rationale: Asking what the surgeon explained clarifies the client's understanding, ensuring informed consent and addressing concerns.
The nurse is caring for a client who is postoperative day 1 after a gastrectomy. Which of the following findings should the nurse report immediately?
- A. Pain at the incision site.
- B. Temperature of 100.8°F (38.2°C).
- C. Nasogastric tube output of 100 mL.
- D. Urine output of 40 mL/hour.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-gastrectomy complication. Options A, C, and D are normal.
The nurse is transporting a mother and her newborn upon discharge from the hospital. When the nurse is assisting the mother and newborn into the car, the nurse notes that the car is equipped with a front-facing car seat that is in the front seat of the car. Which action is most appropriate for the nurse?
- A. Position the infant in the car seat as positioned.
- B. Explain that a rear-facing car seat is necessary and offer to lend the family a car seat from the hospital for the trip home.
- C. Tell the mother that holding the infant is safer than putting the infant in a front-facing car seat.
- D. Place the car seat in the back seat and position the infant appropriately.
Correct Answer: B
Rationale: Infants require rear-facing car seats in the back seat for safety. Offering a hospital car seat ensures proper transport safety.
A client with dementia.
The nurse knows that which of these plans would be MOST successful in caring for a client with dementia?
- A. Teach new skills for adjusting to the aging process.
- B. Adjust the environment to meet the client's individual needs.
- C. Encourage competitive activities to keep the client physically strong.
- D. Provide unstructured activities with frequent changes to increase stimulation.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) unable to learn new skills (2) correct-client with dementia does not have cognitive abilities to learn new skills or to adapt, environment must be adapted for client with attention to safety and predictability (3) requires skills the client with dementia does not have (4) requires skills the client with dementia does not have
A client has been taking propranolol (Inderal) 40 mg bid and furosemide (Lasix) 40 mg qd for several months. Two weeks ago, the physician added verapamil (Calan) 80 mg tid to his medication regimen.
It is MOST important for the nurse to assess for which of the following?
- A. Tachycardia.
- B. Diarrhea.
- C. Peripheral edema.
- D. Impotence.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to medication. (1) will cause bradycardia (2) usually causes constipation (3) correct-Calan is a calcium-channel blocker, depresses myocardial contractility, decreases work of ventricles and O2 demand, dilates coronary arteries, when used with other antihypertensives can cause hypotension and heart failure (4) not most important or frequent side effect