Nokea
A 19-year-old woman after delivery of a 7 lb 10 oz baby boy. The patient has decided to bottle-feed her infant.
The nurse should encourage the patient to
- A. use the manual breast pump to relieve breast engorgement.
- B. apply warm packs to the breast to relieve discomfort.
- C. massage the breasts to reduce engorgement and discomfort.
- D. wear a well supportive bra and take Tylenol for discomfort.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will encourage milk secretion (2) will enhance flow of milk (3) may be taut due to engorgement, massage would be painful and unnecessary, will encourage milk flow (4) correct-will help minimize discomfort during period of engorgement
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A child who received meperidine (Demerol) IM one hour ago.
The nurse knows that which of the following is the BEST assessment indicating relief from abdominal pain for a child who received meperidine (Demerol) IM one hour ago?
- A. The child states that his pain has gone away.
- B. The child's heart rate has changed from 80 to 95.
- C. The child sleeps except when receiving nursing care.
- D. Results from the incentive spirometer have improved.
Correct Answer: D
Rationale: Strategy: Think about what the words mean. (1) contains correct information, but is not a priority; child could deny pain out of fear of getting another injection (2) indicates discomfort, anxiety (3) indicates a need to decrease the amount of medication (4) correct-when pain is decreased, child will be better able to breathe deeply and improve the outcome of use of the incentive spirometer
The home health nurse visits a male client to provide wound care and finds the client lethargic and confused. His partner states he fell down the stairs 2 hours ago. The nurse should
- A. place a call to the client's provider for instructions
- B. send him to the emergency room for evaluation
- C. reassure the client's partner that the symptoms are transient
- D. instruct the client's partner to call the provider if his symptoms become worse
Correct Answer: B
Rationale: This client requires immediate evaluation. A delay in treatment could result in further deterioration of his condition and possibly permanent harm. Home care nurses must prioritize interventions based on assessment findings that are in the client's best interest.
After abdominal surgery, a client is admitted from the recovery room with intravenous fluid infusing at 100 cc/h. One hour later, the nurse finds the clamp wide open and notes that the client has received 850 cc.
The nurse would be MOST concerned by which of the following?
- A. A CVP reading of 12 and bradycardia.
- B. Tachycardia and hypotension.
- C. Dyspnea and oliguria.
- D. Rales and tachycardia.
Correct Answer: D
Rationale: Strategy: 'MOST concerned' indicates a complication. (1) CVP is normal, and bradycardia is incorrect (2) does not contain information relevant to fluid overload (3) does not contain information relevant to fluid overload (4) correct-indicate cardiovascular fluid overload
A low-sodium, high-potassium diet is ordered for a client. Which food selection made by the client indicates understanding of the prescribed diet?
- A. Orange juice, baked chicken, and a cucumber and tomato salad
- B. Milk, roast beef, and spinach salad
- C. Iced tea, fish sandwich, and mixed vegetables
- D. Cola, fried shrimp, and coleslaw
Correct Answer: A
Rationale: Orange juice and vegetables are high in potassium and low in sodium, aligning with the prescribed diet, unlike milk, beef, or fried foods.
The nurse is caring for a client with a suspected myocardial infarction. Which of the following actions should the nurse perform FIRST?
- A. Administer aspirin 325 mg PO.
- B. Apply oxygen at 2 L/min via nasal cannula.
- C. Obtain a 12-lead ECG.
- D. Start an IV line.
Correct Answer: B
Rationale: Applying oxygen is the priority to improve myocardial oxygenation in a suspected myocardial infarction, addressing the immediate threat of hypoxia. Options A, C, and D are important but secondary: aspirin prevents clot progression, ECG confirms diagnosis, and IV access supports medication delivery.