Nokea
A home health nurse is caring for a client who has unilateral mastitis and is experiencing discomfort in the affected breast.
Which of the following instructions should the nurse include?
- A. Suggest the client apply warm compresses to the affected breast
- B. Tell the client to apply hydrocortisone ointment to the affected area of the breast
- C. Encourage the client to limit oral fluid intake to decrease milk production
- D. Recommend the client avoid wearing a nursing bra until symptoms resolve
Correct Answer: A
Rationale: Warm compresses relieve pain, improve circulation, and promote milk flow, aiding in clearing the infection and reducing engorgement.
You may also like to solve these questions
A nurse is reinforcing teaching with a client who is pregnant and reports frequent heartburn.
Which of the following recommendations should the nurse include in the teaching?
- A. Lie in a left side-lying position for 30 min after meals.
- B. Eat three large meals per day.
- C. Drink a cup of black coffee before breakfast.
- D. Take sips of milk between meals.
Correct Answer: D
Rationale: Sips of milk neutralize stomach acid, relieving heartburn without overfilling the stomach.
A nurse is preparing to administer metronidazole 2 g PO. The amount available is 500 mg tablets.
How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero)
Correct Answer: 4 tablets
Rationale: 2 g = 2000 mg; 2000 mg / 500 mg/tablet = 4 tablets.
Medical History: Gravida 1 Para 1, 41 weeks of gestation, Cesarean birth following prolonged rupture of membranes and cephalopelvic disproportion. Vital Signs: Temperature 38.4° C (101.1° F), Blood pressure 118/72 mm Hg, Heart rate 108/min, Respiratory rate 20/min. Breasts: Client reports their breasts are starting to feel firmer and heavier. Denies nipple discomfort. Client is bottle-feeding their newborn. Uterus: Boggy and tender to palpation. Fundus at the umbilicus. Lochia: Moderate amount of dark brown, foul-smelling discharge. Bladder: Client reports frequent voiding without difficulty. Lower extremities: Bilateral edema of lower extremities noted without pain, warmth, or tenderness. Nurses' Notes: Client reports general malaise, chills, and a decreased appetite.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to evaluate the client's progress. Condition Most Likely: ___ Actions to Take: ___ Parameters to Monitor: ___
- A. Plan to administer broad-spectrum antibiotic medication, Administer an oxytocic medication, Apply ice packs to the breasts, Encourage the client to increase fluid intake, Initiate anticoagulant therapy
- B. Engorgement, Endometritis, Deep vein thrombosis, Urinary tract infection
- C. Temperature, Lochia amount and odor, Bladder distension, Integrity of the nipples, Circumference of lower extremities
Correct Answer:
Rationale: The client has fever (38.4°C/101.1°F), tachycardia (HR 108/min), uterine tenderness, and foul-smelling lochia, all of which indicate postpartum uterine infection (endometritis). Administering broad-spectrum antibiotics treats the infection, and oxytocic medication promotes uterine contraction to reduce bacterial growth. Monitoring temperature and lochia amount/odor evaluates treatment progress.
A nurse is planning to administer Rho(D) immune globulin to a client who is postpartum.
Which of the following actions should the nurse take?
- A. Administer the medication into the client's abdomen.
- B. Administer the medication within 72 h after birth
- C. Verify that the newborn is Rh-negative
- D. Verify that the client's Coombs test is positive
Correct Answer: B
Rationale: Rho(D) immune globulin should be given within 72 hours after delivery to prevent Rh isoimmunization in an Rh-negative mother with an Rh-positive newborn.
A nurse is assisting with the care of a client who is in labor and has received nalbuphine hydrochloride.
Which of the following manifestations should the nurse identify as an adverse effect of this medication?
- A. Fever
- B. Diuresis
- C. Diarrhea
- D. Sedation
Correct Answer: D
Rationale: Sedation is a common adverse effect of nalbuphine, an opioid analgesic, causing drowsiness or reduced alertness.