Nokea
The postpartum nurse should include which of the following instructions to breast-feeding mothers?
- A. Limit feeding times for several days to avoid nipple soreness.
- B. Wash the nipples with soap and water before and after each feeding.
- C. Daily caloric intake should be increased by 500 cal.
- D. Breast milk is totally digestible by the baby because it contains lactose.
Correct Answer: C
Rationale: Limiting initial feeding times will only delay nipple soreness as well as the establishment of the letdown reflex, thus encouraging engorgement from clogged ducts and ductules. Soap should be avoided because it may be excessively drying, predisposing nipples to cracking. For optimal milk production, an additional 500 kcal over maintenance levels are needed daily. Lipase, not lactose, emulsifies the fat in breast milk, making it almost totally digestible by infants.
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While the RN is assessing a mother's perineum on her 2nd postpartum day after having a vaginal delivery, the RN notes a large ecchymotic area located to the left of the mother's perineum. Which one of the following interventions should the RN initiate at this time?
- A. Have the client expose the area to air.
- B. Apply ice to the perineum.
- C. Encourage the client to take warm sitz baths.
- D. Inform the physician.
Correct Answer: C
Rationale: Warm sitz baths increase circulation, promote healing, and reduce edema in a traumatized perineum, making it appropriate for an ecchymotic area.
The nurse is caring for a client with a history of Addison’s disease. Which finding indicates a potential adrenal crisis?
- A. Blood pressure of 90/60 mmHg
- B. Weight gain of 2 pounds
- C. Serum sodium of 140 mEq/L
- D. Heart rate of 80 beats per minute
Correct Answer: A
Rationale: Adrenal crisis in Addison’s disease causes hypotension (e.g., 90/60 mmHg) due to cortisol and aldosterone deficiency, leading to shock. Weight gain, normal sodium, and normal heart rate are not indicative.
The nurse is caring for a client who is recovering from a fractured femur. Which diet selection would be best for this client?
- A. Loaded baked potato, fried chicken, and tea
- B. Dressed cheeseburger, French fries, and a Diet Coke
- C. Tuna fish salad on sourdough bread, potato chips, and skim milk
- D. Mandarin orange salad, broiled chicken, and milk
Correct Answer: D
Rationale: A diet for fracture recovery needs protein, calcium, and vitamin C. Mandarin orange salad (vitamin C), broiled chicken (protein), and milk (calcium) (D) are optimal. Other options are less nutrient-dense.
The nurse is caring for a client with a brain tumor who has been prescribed levofloxacin (Levaquin) for a sinus infection. What specific instructions should be included when educating the client regarding taking this drug?
- A. Avoid direct sunlight.
- B. Report unexplained joint pain.
- C. No antacids should be taken within 2 hours of taking the drug.
- D. Take the medication on an empty stomach.
- E. Keep the head of the bed elevated for 30 minutes after taking.
Correct Answer: A, B, C
Rationale: Levofloxacin requires avoiding sunlight (A) due to photosensitivity, reporting joint pain (B) for tendonitis risk, and avoiding antacids (C) to ensure absorption. Empty stomach (D) is optional, and bed elevation (E) is unrelated.
A client had a right below-the-knee amputation 4 days ago. He is complaining of pain in his right lower leg. The nurse should:
- A. Remind the client that he no longer has that part of his leg and assure him he will be OK
- B. Call the physician to request a psychological consultation for the client
- C. Turn on the television to distract the client's attention from his amputated leg
- D. Give the client his order of Demerol 50 mg IM prn
Correct Answer: D
Rationale: Phantom pain is a normal, very real experience for an amputee and should be treated with pain medication.