Nokea
When a breast-feeding mother reports experiencing nipple soreness, the nurse provides teaching regarding measures to relieve the soreness. Which statement by the mother indicates an understanding of the teaching?
- A. I need to avoid rotating breast-feeding positions so that the nipple will toughen.
- B. I need to stop nursing during the period of nipple soreness to allow the nipples to heal.
- C. I need to nurse less frequently and substitute a bottle feeding until the nipples become less sore.
- D. I need to position my infant with her ear, shoulder, and hip in straight alignment and place her stomach against me.
Correct Answer: D
Rationale: Comfort measures for nipple soreness include positioning the infant with the ear, shoulder, and hip in straight alignment and with the infant's stomach against the mother's. Additional measures include rotating breastfeeding positions, breaking suction with the little finger, nursing frequently, beginning feeding on the less sore nipple, not allowing the infant to chew on the nipple or to sleep holding the nipple in the mouth, and applying tea bags soaked in warm water to the nipple. The remaining options are incorrect statements.
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The nurse is preparing to implement emergency care measures for the client who has just demonstrated signs and symptoms of a pulmonary embolism. Which primary health care provider prescription should the nurse implement first?
- A. Apply oxygen.
- B. Administer morphine sulfate.
- C. Start an intravenous (IV) line.
- D. Obtain an electrocardiogram (ECG).
Correct Answer: A
Rationale: The client needs oxygen immediately because of hypoxemia, which is most often accompanied by respiratory distress and cyanosis. The client should also have an IV line for the administration of emergency medications such as morphine sulfate. An ECG is useful in determining the presence of possible right ventricular hypertrophy. All of the interventions listed are appropriate, but the client needs the oxygen first.
A client is admitted to the hospital after sustaining a fall from a roof. The client has multiple lacerations and a right leg fracture, which has been treated with a plaster cast. How should the nurse position the client's leg to promote optimal circulation?
- A. Flat or a level position
- B. Flat for 3 hours and elevated for 1 hour
- C. Elevated for 3 hours, and then flat for 1 hour
- D. Elevated on pillows continuously for 24 to 48 hours
Correct Answer: D
Rationale: A casted extremity is elevated continuously for the first 24 to 48 hours to minimize swelling and promote venous drainage. The other options are not part of standard positioning of the newly casted extremity.
A client had a positive Papanicolaou smear and underwent cryosurgery with laser therapy. What information should the nurse provide the client as a part of discharge teaching?
- A. Pain can be relieved with opioid analgesics.
- B. Sitz baths are soothing to the irritated tissues.
- C. Vaginal discharge should be clear and watery.
- D. There should be absolutely no odor or vaginal discharge.
Correct Answer: C
Rationale: Cryosurgery is a procedure that involves freezing cervical tissues. Vaginal discharge should be clear and watery after the procedure. There is mild pain after the procedure, but opioid analgesics would not be required. Tub and sitz baths are avoided while the area is healing, which takes about 10 weeks. The client will begin to slough off dead cell debris, which may be odorous. This resolves within approximately 8 weeks.
Pelvic inflammatory disease is most often caused by:
- A. Trichomoniasis
- B. E. coli
- C. Staphylococcus aureus
- D. Neisseria gonorrhoeae
Correct Answer: D
Rationale: Neisseria gonorrhoeae is a common cause of pelvic inflammatory disease, often resulting from untreated gonorrhea, leading to infection of the reproductive organs.
A client with a history of type 2 diabetes is prescribed exenatide (Byetta). The nurse should instruct the client to:
- A. Take the medication before meals.
- B. Monitor for signs of hypoglycemia.
- C. Take the medication at bedtime.
- D. Stop the medication if weight loss occurs.
Correct Answer: A, B
Rationale: Exenatide is taken before meals to control postprandial glucose, and hypoglycemia is a risk.