Teaching & Learning / Patient Education

What steps should be included in the teaching plan for a client being discharged with an EpiPen autoinjector? Place the steps in chronological order. All options must be used.

Remove the autoinjector from its carrying tube. Grasp the unit with the injecting end pointing downward. With the other hand, remove the blue safety release cap. Swing and jab firmly into the outer thigh until a click is heard. Hold firmly against the thigh for 10 seconds. Massage the thigh. Explanation: When teaching self-administration, the nurse should teach the client to: Remove the autoinjector from its carrying tube, grasp the unit with the injecting end pointing downward, with the other hand, remove the blue safety release cap, swing and jab firmly into the outer thigh until a click is heard, hold firmly against the thigh for 10 seconds, and massage the thigh.

The nurse instructs a group of parents about emergency treatment for accidental poisoning and injury. The nurse will need to do further teaching if a participant makes which statement? "I shouldn't induce vomiting unless the poison control center instructs me to." "I should save the emesis if my child vomits." "I should flush my child's eye with room temperature tap water for 15 to 20 minutes if a caustic material gets into it." "I should call the poison control center if there are any symptoms."

"I should call the poison control center if there are any symptoms." Explanation: Many poisons require immediate attention but do not cause immediate symptoms. Therefore, parents who believe that a child has ingested or otherwise been exposed to a poisonous substance should immediately call the Poison Control Center and not wait for symptoms to present. Eyes should be flushed for 15 to 20 minutes with saline or room-temperature tap water. Emesis should be saved for analysis, especially if the type or amount of poison ingested is not clear. Vomiting caustic substances may lead to esophageal or airway damage; therefore, vomiting should only be induced if directed by the Poison Control Center.

A client who is having an abdominal perineal resection with permanent colostomy asks, "Where will my colostomy be placed?" Which should the nurse tell the client? "Do you have a preference on the placement of it?" "The surgeon will decide that during surgery." "In the midline of the abdomen, near your umbilicus." "A permanent colostomy is usually located on the left side of the abdomen."

"A permanent colostomy is usually located on the left side of the abdomen." Explanation: Because the colon normally absorbs large quantities of water, placing the colostomy near the end of the colon will result in near-normal stool consistency. Optimal placement of an ostomy is usually determined by an enterostomal therapist before surgery. Client preference will not be the determining factor in ostomy placement. The enterostomal therapist will work closely with the client to select the optimal site. When possible, the preferred site for a permanent colostomy is in the lower portion of the descending colon; hence, placement is on the left side of the body.

A nurse is teaching a client with glaucoma the proper technique for instilling eye drops. The nurse determines that teaching is effective when the client states: "I should instill the drop near the opening of the lacrimal duct." "I should instill the drop in the lower conjunctival sac." "I should instill the drop directly onto the cornea." "I should instill the drop in the outer canthus."

"I should instill the drop in the lower conjunctival sac." Explanation: Eye drops should be placed in the lower conjunctival sac starting at the inner, not outer, canthus. Placing eye drops on the cornea causes discomfort and should be avoided. Eye drops shouldn't be placed by the opening of the lacrimal ducts to avoid systemic absorption.

A client admitted for treatment of a gastric ulcer is being prepared for discharge on antacid therapy. Which statement made by the client indicates understanding of discharge teaching? "My antacid will work best if I take it with my meals." "I should not take antacids with magnesium, because I have a heart problem." "I'll continue to take my antacid even if I feel better." "I'll take my antacid in the morning with my other medications."

"I'll continue to take my antacid even if I feel better." Explanation: Antacids decrease gastric acidity and should be continued even if the client's symptoms subside. Because other medications may interfere with antacid action, the client should avoid taking antacids concomitantly with other drugs. If cardiac problems arise, the client should avoid antacids containing sodium, not magnesium. For optimal results, the client should take an antacid 1 hour before or 2 hours after meals.

An adolescent with cystic fibrosis has been placed on ciprofloxacin for a lung infection. Which statement from the client indicates the need for more teaching? "I should immediately report any muscle or joint pain." "I'll need to have drug levels drawn while I'm on this medication." "I won't take this drug with any dairy products." "If I miss a dose, I should take it as soon as I remember."

"I'll need to have drug levels drawn while I'm on this medication." Explanation: Therapeutic serum drug monitoring is not routinely done with ciprofloxacin. This medicine should not be taken with dairy products or other significant sources of calcium such as collard greens, calcium supplements, calcium carbonate antacids, or calcium-fortified juice. Clients may take a missed dose as soon as they remember. If it is very close to the time of the next dose, the missed dose should be omitted. The client should not take a double dose.

A client's spouse has expressed great concern about the fact that antibiotics have been prescribed for the treatment of pneumonia. The spouse states, "I do not trust all these pharmaceuticals. We are going to treat the pneumonia using the magnet therapy I read about online." What is the nurse's best response? "Are you refusing to take the prescribed antibiotics?" "Try not to worry. Your spouse needs to make decisions about the treatment." "I will contact the pharmacist and we can have a discussion about prescribed antibiotics." "It sounds like you have some important questions about the use of medication."

"It sounds like you have some important questions about the use of medication." Explanation: When clients present information that is inaccurate or unfounded, the nurse should use this opportunity to discuss the client's doubts and reservations. The nurse needs to obtain more information. A confrontational or condescending approach such as asking about refusal is disrespectful and is unlikely to have the desired effect. The nurse needs to accept what the spouse is saying and provide further information. Contacting the pharmacist is helpful but more information is needed to explore ideas for treatment

The nurse is evaluating a child's skills in self-administering insulin (see figure). What should the nurse do? Tell the child to use a site lower on their thigh. Remind the child to rotate sites. Have the child use both hands on the syringe. Ask the child to place the needle at a 45-degree angle.

Remind the child to rotate sites. Explanation: The child is using the correct injection technique, and the nurse can remind the child to rotate sites. The nurse should also reinforce that the child has used the correct technique and praise the child for doing so. If the child can manipulate the plunger of the syringe with one hand, this is appropriate. Insulin is administered at a 90-degree angle as shown. The child should identify appropriate sites on the thighs as one handbreadth below the hip and above the knee; the child is using appropriate sites.

A client asks a nurse a question about the tuberculin skin test for tuberculosis. The nurse should base their response on the fact that the skin test doesn't differentiate between active and dormant tuberculosis infection. area of redness is measured in 3 days and determines whether tuberculosis is present. presence of a wheal at the injection site in 2 days indicates active tuberculosis. test stimulates a reddened response in some clients and requires a second test in 3 months.

skin test doesn't differentiate between active and dormant tuberculosis infection. Explanation: The tuberculin skin test doesn't differentiate between active and dormant infections. If a positive reaction occurs, a sputum smear and culture as well as a chest X-ray are necessary to provide more information. Although the area of redness is measured in 3 days, a second test may be needed; neither test indicates that tuberculosis is active. In the tuberculin skin test, an induration 5 to 9 mm in diameter indicates a borderline reaction; a larger induration indicates a positive reaction. The presence of a wheal within 2 days doesn't indicate active tuberculosis

The nurse teaches the parent of a toddler diagnosed with nephrotic syndrome about the disease. Which statement by the parent indicates that they understood the nurse's teaching about this disease? "My child really likes chips and bologna. I guess we'll have to find something else." "We will have to encourage lots of liquids. Did you say about 17 cups (4 L) every day?" "We understand the need for antibiotics. I just wish the antibiotics could be given by mouth." "We worry about the surgery. Do you think we should do a direct donation of blood?"

"My child really likes chips and bologna. I guess we'll have to find something else." Explanation: Children with nephrotic syndrome usually require sodium restriction. Because potato chips and bologna are high in sodium, the parent's statement about finding something else reflects an understanding of this need. Although fluid intake is not restricted in children with nephrotic syndrome, 17 cups (4 L) is an excessive amount for a toddler. The typical fluid requirement for a toddler is 115 mL/kg. Surgical intervention and antibiotic therapy are not parts of the treatment plan for nephrotic syndrome.

Which instruction is most important for the nurse to include in the teaching plan for a client who is taking phenelzine? Eat a normal amount of salt in the diet. Allow 10 days to achieve therapeutic effects. Avoid foods high in tyramine. Drink 10 to 12 glasses of water each day.

Avoid foods high in tyramine. Explanation: A client who is taking phenelzine, a monoamine oxidase inhibitor, needs to avoid foods that are rich in tyramine because this food-drug combination can cause hypertensive crisis. The client should be given a list of foods to avoid and should report headaches, palpitations, and a stiff neck to the health care provider (HCP) immediately. The client does not need to restrict or add salt to the diet. Drinking 10 to 12 glasses of water each day is important to teach the client who is receiving lithium therapy. Antidepressant drugs take 2 to 4 weeks to achieve therapeutic effects.

The nurse at the gynecologic clinic is teaching the client about the results of her Papanicolaou test, which demonstrated dysplasia. Which represents the nurse's best intervention? Ask the client about any family history of cervical cancer. Assist the client to schedule a treatment plan for cervical cancer. Encourage the client to express feelings about cervical cancer. Explain that the results show cervical changes that require follow up.

Explain that the results show cervical changes that require follow up. Explanation: Dysplasia, a precancerous condition, refers to an alteration in the size, shape, and organization of differentiated cells. The client will need further diagnostic evaluation to determine the scope of and treatment for the problem. Because the client does not have a diagnosis of cervical cancer, it is inappropriate to begin a treatment plan. Cervical cancer may run in families, but this is not the most important risk factor: infection with Human Papilloma Virus (HPV) and smoking are greater risk factors. Therefore, asking about family history is not the best intervention at this time. Encouraging the client to express feelings about cervical cancer is premature as the client is in a precancerous stage and requires follow up.

The nurse instructs the client in mixing and administering regular and NPH insulin. Which statement indicates that the client needs additional instruction? "I shake the bottle of NPH insulin before drawing it up." "I insert the needle at a 90-degree angle." "I draw up the regular insulin first." "I store the insulin in a cool place."

"I shake the bottle of NPH insulin before drawing it up." Explanation: When instructing the client about mixing two types of insulin in the same syringe, the nurse should instruct the client about how to handle the insulin and which one to draw up first. NPH insulin should be rolled between the palms to mix it before drawing it up; shaking it will introduce air bubbles into the solution, which can cause inaccurate dosing. The nurse should also verify that the client understands they should draw up the most rapid-acting insulin first; the client states they are drawing up the regular insulin first. Additionally, the nurse can verify that the client understands to store the insulin in a cool place and inject the insulin at a 90-degree angle.

The nurse is teaching a client with abdominal cancer about taking medication to control the pain? What statement from the client indicates the need for additional teaching? "It's okay to take my pain medication even if I'm not having any pain." "I should take my medication around the clock to control my pain." "I should skip doses periodically so I don't get hooked on my drugs." "I should contact the oncology nurse if my pain isn't effectively controlled."

"I should skip doses periodically so I don't get hooked on my drugs." Explanation: The client should not skip dosages of pain medication to prevent addiction. Clients with cancer pain do not become psychologically dependent on the medication and should not fear becoming addicted. The nurse should allow the client and family members to verbalize their concerns about drug addiction.

A client weighs 300 lb (136 kg) and has a history of deep vein thrombosis and thrombophlebitis. When coaching a client about behaviors to maintain health, the nurse determines that the client has understood the nurse's instructions when the client makes which statement? "I'll try to lose weight by following a reduced-calorie, balanced diet." "I'll limit exercise that involves walking." "I'll perform leg lifts every 4 hours to strengthen hamstring muscles." "I'll wear knee-high stockings, rolled at the top to hold the stockings up."

"I'll try to lose weight by following a reduced-calorie, balanced diet." Explanation: The client is at risk for the development of varicose veins. Therefore, prevention is key in the treatment plan. Maintaining an ideal body weight is the goal. To achieve this, the client should consume a balanced diet and participate in a regular exercise program. Performing leg lifts improves muscle strength, but it is more important for the client to increase exercise by walking. Wearing support stockings is helpful to promote circulation, but the client should not roll the stockings at the top to hold the stockings up as this will decrease circulation at the knees.

The nurse teaches a child's parent about sickle cell disease. Which statement by the parent would indicate the need for additional teaching? "My child is going to be playing on a soccer team when they're feeling better." "I've started to give my child some extra fluids with and between meals." "I've told my spouse that we are both carriers of the disease." "I'm concerned about how the hospital staff will manage my child's pain."

"My child is going to be playing on a soccer team when they're feeling better." Explanation: Physical and emotional stress can precipitate a sickle cell crisis. Physical exercise such as running involved in soccer would increase the child's risk for a crisis. Thus, the parent needs additional instruction about this area. Providing extra fluids with and in between meals is appropriate because it is important for the child with sickle cell disease to keep well hydrated. In addition, these children commonly have nephritis related to sickle cell disease and have difficulty conserving fluids. Therefore, they need up to 150% of normal fluid intake. Pain control is an issue in sickle cell crisis. The parent is showing concern for their child by asking how pain will be managed. Sickle cell disease is an autosomal recessive disease. For the child to have the disease, both parents must carry the recessive gene.

A parent brings her 6-year-old daughter to the pediatrician's office for evaluation. The child recently started wetting the bed and running a low-grade fever. A urinalysis is positive for bacteria and protein. A urinary tract infection (UTI) is diagnosed, and the child is prescribed antibiotics. Which nursing interventions are appropriate? Select all that apply. Assess the parent's understanding of UTI and its causes. Tell the parent to have the child wipe the back to the front after voiding and defecation. Provide instructions only to the parent, not the child. Instruct the parent to administer the antibiotic as prescribed, even if the symptoms diminish. Limit fluids for the next few days to decrease the frequency of urination.

Assess the parent's understanding of UTI and its causes. Instruct the parent to administer the antibiotic as prescribed, even if the symptoms Explanation: Assessing the parent's understanding of UTI and its causes provides the nurse with a baseline for teaching. The full course of antibiotics must be taken to eradicate the organism and prevent recurrence, even if the child's signs and symptoms decrease. Fluids should be encouraged, not limited, to prevent urinary stasis and help flush the organism from the urinary tract. Instructions should be given at the child's level of comprehension to help the child better understand the treatment and promote compliance. The child should wipe from the front to the back, not back to front, to minimize the risk of contamination after elimination.

When talking with 10-year-old children about death, the nurse should incorporate which guidelines? Select all that apply. The children will know that death is inevitable and irreversible. Teach children that death is the same as going to sleep as a way of relieving fear. Teaching about death and dying should not start before age 11 years. Attitudes of the adults in their lives will influence the children. Logical explanations are not appropriate. The children will be curious about the physical aspects of death.

The children will be curious about the physical aspects of death. The children will know that death is inevitable and irreversible. Attitudes of the adults in their lives will influence the children. Explanation: By age 10 years, most children know that death is universal, inevitable, and irreversible. School-age children are curious about the physical aspects of death and may wonder what happens to the body. Their cognitive abilities are advanced and they respond well to logical explanations. They should be encouraged to ask questions. The adults in their environment influence their attitudes toward death. Adults should be encouraged to include children in the family rituals and should be prepared to answer questions that might seem shocking. Teaching about death should begin early in childhood. Comparing death to sleep can be frightening for children and cause them to fear falling asleep.

The nurse is observing a student nurse perform an irrigation of a client's nasogastric (NG) tube. Which action by the student nurse would cause the nurse to stop the procedure? The student nurse allows the fluid in the syringe to flow by gravity into the NG tube. The student nurse puts on clean gloves instead of sterile gloves. The student nurse disconnects the suction tubing from the NG tube. The student nurse irrigates the NG tube through the blue air vent port.

The student nurse irrigates the NG tube through the blue air vent port. Explanation: The student nurse would not want to instill fluid through the blue air vent port - this is reserved for air only and is a way to decrease pressure that can build up into the stomach when suction is used. The student nurse should wear clean not sterile gloves because it is not a sterile procedure. The student nurse would disconnect the suction tubing in order to attach the syringe and can use gravity versus pushing the fluid in to instill it.

The nurse teaches appropriate care measures to the parents of a 5-year-old child who has been given trimethoprim/sulfamethoxazole for a urinary tract infection. What directives should be included in the teaching plan? Select all that apply. Administer medication with milk or food. Report any rash. Keep the child well hydrated. Keep medication out of the sunlight. Use a sunscreen.

Use a sunscreen. Report any rash. Keep medication out of the sunlight. Keep the child well hydrated. Explanation: The child receiving trimethoprim/sulfamethoxazole should wear sunscreen daily while on the medication, and the medication must be kept out of direct sunlight. (It comes in a dark bottle.) Children with a urinary tract infection should drink lots of fluids to help flush the organisms from the bladder. The medication does need to be taken with milk or food. Trimethoprim/sulfamethoxazole has been associated with Steven-Johnson syndrome, so any rash requires prompt attention.

A client is 4 days postoperative from a tibia fracture and has a long leg cast. The nurse is conducting initial teaching for walking with crutches. What is the most important activity for the nurse to encourage the client to do prior to discharge from the hospital? keep the affected limb in extension and abduction at all times. sit up straight in a chair to develop the back muscles, as this will help the client walk with crutches. while walking, do weight bearing on the cast to increase balance. conduct exercises in bed to strengthen the upper extremities, as this will assist the client in crutch use.

conduct exercises in bed to strengthen the upper extremities, as this will assist the client in crutch use. Explanation: When walking with crutches, the client engages the triceps, trapezius, and latissimus muscles. A client who has been immobilized may need to implement an exercise program to strengthen these shoulder and upper arm muscles before initiating crutch walking. The other choices are incorrect based on functionality and muscle use.

After a plaster cast has been applied to the arm of a child with a fractured right humerus, the nurse completes discharge teaching. The nurse should evaluate the teaching as successful when the birth parent agrees to seek medical advice if the child experiences which symptom? inability to extend the fingers on the right hand coolness and dampness of the cast after 5 hours vomiting after the cast is applied fussiness with statements that the cast is heavy

inability to extend the fingers on the right hand Explanation: Inability to extend the fingers of the involved arm may indicate neurologic impairment caused by pressure on soft tissue. It is not unusual for a child to vomit after experiencing a traumatic injury. It may take up to 72 hours for a plaster cast to dry. Until the cast dries, the dampness causes the sensation of coolness. The cast will seem heavy until the child adjusts to the extra weight. The child may exhibit fussiness (such as whining, crying, or clinging) as a result of numerous causes, such as placement of the cast, the hospital experience, or pain. These reactions are normal and do not warrant medical advice.

The nurse is observing a nursing student palpating a client's maxillary sinuses. The nurse observes that the student has correctly palpated the client's maxillary sinuses when the student palpates which area? below the client's cheekbones on the bridge of the client's nose over the client's temporal area below the client's eyebrows

below the client's cheekbones Explanation: To palpate the maxillary sinuses, the nurse would place hands on either side of the client's nose, below the cheekbone (zygomatic bone). To palpate the frontal sinuses, the nurse places their thumb just above the client's eye, under the bony ridge of the orbit. No sinuses are located on the bridge of the nose or in the temporal area.

A client is receiving vincristine. What should the nurse instruct the client to do when taking this drug? Follow a low-fiber, bland diet. Restrict fluids to 6 cups (about 1½ L) a day. Take a stool softener daily. Use loperamide for diarrhea.

Take a stool softener daily. Explanation: A side effect of vincristine is constipation, and the nurse should encourage the client to include high fiber in the diet and drink 10½ to 12 cups (about 2½ to 3 L) of fluids each day. The nurse can instruct the client to take a stool softener as needed and before receiving a dose of vincristine. Loperamide is used to treat diarrhea, and it is not appropriate unless the client has diarrhea.

When teaching a caregiver of a school-age client about signs and symptoms accompanying fever that require immediate notification of the physician, which description should the nurse include? cough progressing to productive sputum history of febrile seizures reports of a stiff neck burning or pain with urination

reports of a stiff neck Explanation: The nurse should discuss reports of a stiff neck because fever and a stiff neck indicate possible meningitis. Burning or pain with urination, a cough that progresses to productive sputum, and a history of febrile seizures should be addressed by the physician but can wait until office hours.

When educating the client with type 1 diabetes, the nurse knows that more education is needed when the client says: "I will need to give myself insulin every day." "I will need to eliminate sugar from my diet." "I will be able to switch to insulin pills when my sugar is under control." "I will need to go to the podiatrist to get my toenails cut so I don't get an infection."

"I will be able to switch to insulin pills when my sugar is under control." Explanation: Oral antidiabetic agents are effective only in adult clients with type 2 diabetes. Oral antidiabetic agents aren't effective in type 1 diabetes. The need to eliminate sugar, give insulin, and receive proper foot care are all items that indicate the client understands the teaching.

The health care provider (HCP) has prescribed insulin detemir for a client with type 2 diabetes requiring insulin. What should the nurse teach the client about this insulin? "You do not need to rotate injection sites with this insulin." "You may increase the carbohydrates in your diet when using this insulin." "You do not mix insulin detemir; the solution is clear." "You may refill the detemir insulin pen."

"You do not mix insulin detemir; the solution is clear." Explanation: Insulin detemir is used only if the solution appears clear and colorless with no visible particles. Insulin detemir is not diluted or mixed with any other insulin preparations. As with any insulin therapy, lipodystrophy may occur at the injection site and delay insulin absorption. Continuous rotation of the injection site within a given area may help to reduce or prevent this reaction. The client should continue to follow the prescribed diet and monitor glucose levels when taking insulin detemir. Insulin detemir is available in a prefilled insulin pen. When the insulin pen is empty, it may not be refilled; instead, the pen is discarded.

A nurse is providing education in a community setting about general measures to avoid excessive sun exposure. Which recommendation is appropriate? Use sunscreen only after going into the water. Apply sunscreen with a sun protection factor (SPF) of 15 or more before sun exposure. Avoid peak exposure hours from 0900 to 1300. Wear loosely woven clothing for added ventilation.

Apply sunscreen with a sun protection factor (SPF) of 15 or more before sun exposure. Explanation: A sunscreen with an SPF of 15 or higher should be worn on all sun-exposed skin surfaces. It should be applied before sun exposure and reapplied after being in the water. Peak sun exposure usually occurs from 0010 to 1400. Tightly woven clothing, protective hats, and sunglasses are recommended to decrease sun exposure. Sun tanning parlors should be avoided.

The nurse is developing a teaching plan with a client who is taking warfarin sodium. What should the nurse include in the plan? Avoid the use of a toothbrush during oral hygiene. Use rectal suppositories to treat constipation. Eat green leafy vegetables. Consult the health care provider (HCP) before undergoing a tooth extraction.

Consult the health care provider (HCP) before undergoing a tooth extraction. Explanation: Clients who are receiving anticoagulant therapy should consult the HCP before undergoing any dental work that will cause bleeding such as a tooth extraction. The dentist should also be aware that the client is taking anticoagulants. A soft toothbrush is desirable for oral hygiene if the client is receiving anticoagulant therapy; it helps prevent the gums from bleeding. Rectal suppositories are contraindicated during anticoagulant therapy because their insertion may cause bleeding. Stool softeners may be used instead to prevent straining, which also may promote bleeding. Green leafy vegetables should not be eaten in excess because of their vitamin K content, which may alter the effectiveness of the anticoagulant therapy.

Which instruction should be included in the discharge teaching plan for a client after thyroidectomy for Graves' disease? Have regular follow-up care. Keep an accurate record of intake and output. Exercise to improve cardiovascular fitness. Use nasal desmopressin acetate (DDAVP).

Have regular follow-up care. Explanation: The nurse should instruct the client with Graves' disease to have regular follow-up care because most cases of Graves' disease eventually result in hypothyroidism. Annual thyroid-stimulating hormone tests and the client's ability to recognize signs and symptoms of thyroid dysfunction will help detect thyroid abnormalities early. Recording intake and output is important for clients with fluid and electrolyte imbalances but not thyroid disorders. DDAVP is used to treat diabetes insipidus. Although exercise to improve cardiovascular fitness is important, the importance of regular follow-up is most critical for this client.

The nurse develops the preoperative teaching plan for a 14-month-old child with an undescended testis who is scheduled to have surgery. Which method is most appropriate? Tell the child that they will not see any incisions after surgery. Explain to the parents how the defect will be corrected. Use an anatomically correct doll to show the child what will be "fixed." Tell the child that their penis and scrotum will be "fixed."

Explain to the parents how the defect will be corrected. Explanation: Preoperative teaching would be directed at the parents because the child is too young to understand the teaching. Telling the child that their penis and scrotum will be "fixed," telling the child they will not see incisions after surgery, and using a doll to illustrate the surgery are appropriate interventions for a preschool-age child.

A client in early labor tells the nurse that she has a thick, yellow discharge from both of her breasts. What is the nurse's most appropriate intervention? Complete a thorough breast examination and document the results in the chart. Inform the client that the discharge is colostrum, and a normal finding. Perform a culture on the discharge, and inform the client that she might have mastitis. Tell her that her milk is starting to come in because she's in labor.

Inform the client that the discharge is colostrum, and a normal finding. Explanation: After the fourth month, colostrum may be expressed. The breasts normally produce colostrum for the first few days after birth. Milk production begins one to three days postpartum. A clinical breast examination isn't usually indicated in the intrapartum setting. Although a culture may be indicated, it requires advanced assessment as well as a medical order.

A nurse explains the process of cane usage to a hospitalized client with left-sided weakness. Place the steps of teaching proper cane usage in the correct order. All options must be used.

Perform hand hygiene. Secure a gait belt around client's waist. Place the cane in the right hand. Have client advance the cane and the left leg. Have client advance the right leg. Explanation: First, perform hand hygiene. Next, secure a gait belt around client's waist. Then, place the cane in the client's right hand, because the right side is the unaffected side. Have the client advance the cane and the left leg about 4 to 8 inches (10 to 20 cm). Finally, have the client advance the right leg the same distance.

A school nurse has been asked to conduct a sexuality education class for fourth grade children. What is the most effective method for the nurse to use to present the material to the children? Provide booklets that children take home to read. Deliver a coeducation sexual education class. Use dolls to illustrate examples of sexual expressions. Read sexual education pamphlets with the children.

Read sexual education pamphlets with the children. Explanation: Reading the pamphlets with the children shows that the nurse is available to answer questions, and it can prompt specific discussion as the material is read together. The use of dolls is not used for children at a fourth grade level. Sexuality education classes are most beneficial if they are same-sex classes, which foster a safer environment for asking questions. Giving school-age children pamphlets to read out of the presence of the nurse is ineffective because the children will rarely seek out the nurse to ask questions at another time.

The health care provider prescribes sulfasalazine for the client with ulcerative colitis. Which instruction should the nurse give the client about taking this medication? Stop taking it if urine turns orange-yellow. Take it with a full glass (240 mL) of water. Avoid taking it with food. Take the total dose at bedtime.

Take it with a full glass (240 mL) of water. Explanation: Adequate fluid intake of at least eight glasses (1893 mL) a day prevents crystalluria and stone formation during sulfasalazine therapy. Sulfasalazine can cause gastrointestinal distress and is best taken after meals and in equally divided doses. Sulfasalazine gives alkaline urine an orange-yellow color, but it is not necessary to stop the drug when this occurs.

A nurse is teaching a client with chronic bronchitis about breathing exercises. Which instruction should the nurse include in the teaching? Make inhalation longer than exhalation. Use diaphragmatic breathing. Exhale through an open mouth. Use chest breathing.

Use diaphragmatic breathing. Explanation: In chronic bronchitis the diaphragm is flat and weak. Diaphragmatic breathing helps to strengthen the diaphragm and maximizes ventilation. Exhalation should be longer than inhalation to prevent collapse of the bronchioles. The client with chronic bronchitis should exhale through pursed lips to prolong exhalation, keep the bronchioles from collapsing, and prevent air trapping. Diaphragmatic breathing — not chest breathing — increases lung expansion.

A client is taking iron supplements. What information should the nurse give the client? The stools will become darker. Iron supplements should be taken on an empty stomach. Liquid iron supplements will not discolor teeth. Do not use a bulk laxative.

The stools will become darker. Explanation: Iron supplements will darken the stools. Iron supplements should not be taken on an empty stomach because they can cause gastric irritation. Iron is constipating, and a daily bulk-forming laxative should be started prophylactically. A straw should be used when taking liquid iron to avoid discoloring the teeth.

The nurse is providing discharge instructions about preventing infection to a client who had a modified radical mastectomy and will be pruning flowers when they return to work. To prevent infection, what should the nurse instruct the client to do? Keep cuticles cut. Avoid crowded areas. Wear protective gloves when gardening. Remove underarm hair with a sharp razor.

Wear protective gloves when gardening. Explanation: This client is at risk for lymphedema and infection. Precautions to avoid creating an entry site for infection in the affected arm include wearing protective gloves, using cuticle cream, not cutting cuticles, using an electric razor, using a thimble when sewing, and avoiding having injections or blood drawn from that arm. They do not need to avoid crowds; the client is not at high risk for respiratory infection.

The nurse is providing discharge instructions about preventing infection to a client who had a modified radical mastectomy and will be pruning flowers when they return to work. To prevent infection, what should the nurse instruct the client to do? Wear protective gloves when gardening. Remove underarm hair with a sharp razor. Keep cuticles cut. Avoid crowded areas.

Wear protective gloves when gardening. Explanation: This client is at risk for lymphedema and infection. Precautions to avoid creating an entry site for infection in the affected arm include wearing protective gloves, using cuticle cream, not cutting cuticles, using an electric razor, using a thimble when sewing, and avoiding having injections or blood drawn from that arm. They do not need to avoid crowds; the client is not at high risk for respiratory infection.

The client is seen in the clinic for acute gouty arthritis. The healthcare provider orders indomethacin. What should the nurse include in the client's teaching concerning the administration of indomethacin? Select all that apply. "You should have periodic eye exams." "Do not use aspirin with indomethacin." "You should take muscle relaxers for pain." "You should eat high-fiber foods." "You should consider a replacement for indomethacin."

You should have periodic eye exams." "Do not use aspirin with indomethacin." Explanation: Indomethacin can cause problems with vision or balance, so the client should have periodic eye exams. Aspirin/NSAIDs should not be used with indomethacin, as it can cause bleeding or perforation. Teaching about intake of high-fiber foods, taking NSAIDs for pain, and replacing certain medications used for depression/seizures is directed at opioid administration.

A nurse is teaching a group of middle-aged adults about how they can best support brain function as they age. Which supportive behavior demonstrated by the clients would indicate that the mental health nurse's teaching was effective? conserving energy with frequent rest periods eating a high-protein, low-fat diet completing annual physicals using methods of intellectual stimulation

using methods of intellectual stimulation Explanation: Intellectual activity stimulates brain cells to develop new dendrites. Intellectual stimuli assist the aged client to maintain cognitive functioning. Eating a high-protein, low-fat diet has no impact on intellectual acuity. Conservation of energy by frequent rest periods would not result in increased cognitive ability.

A nurse is evaluating the effectiveness of teaching a client about how to self-administer insulin. Which action indicates that additional teaching is necessary? The client: identifies that the syringe is U-100 waits 30 minutes to eat breakfast after injecting rapid-acting insulin rotates sites from legs to arms. draws up the regular insulin first and then the NPH.

waits 30 minutes to eat breakfast after injecting rapid-acting insulin Explanation: The nurse instructs the client to not wait any longer than 5 to 15 minutes to eat after injecting rapid-acting insulin, which has an onset action of 5 minutes and a duration of 1 hour. The client is using the proper technique for mixing the insulins, rotating sites, and using the U-100 syringe.

A client has been diagnosed with legionellosis (Legionnaires' disease). The client asks, "How did I get this?" Which response by the nurse is the most accurate? "As ceiling fans circulate, bacteria are dispersed into the air." "The bacteria are inhaled from contaminated water droplets." "You inhaled the bacteria in a smoke-filled room. " "You may have swallowed bacteria-contaminated water."

"The bacteria are inhaled from contaminated water droplets." Explanation: Legionellosis is a pneumonia caused by the bacterium Legionella pneumophilia that thrives in water that is 95° to 115° F (35° to 46° C). When a building's hot water plumbing has water at this temperature, the bacteria thrive; then they may be transmitted via inhalation from air conditioning, showers, spas, and whirlpools. The bacteria are not transmitted via smoke or ceiling fan blades or by swallowing contaminated water.

An elderly client asks the nurse how to treat chronic constipation. What is the best recommendation the nurse can make? Administer a tap-water enema weekly. Take a mild laxative such as magnesium citrate when necessary. Administer a phospho-soda enema when necessary. Take a stool softener such as docusate sodium daily.

Take a stool softener such as docusate sodium daily. Explanation: Stool softeners taken daily promote absorption of liquid into the stool, creating a softer mass. They may be taken on a daily basis without developing a dependence. Dependence is an adverse effect of daily laxative use. Enemas used daily or on a frequent basis can also lead to dependence of the bowel on an external source of stimulation

A nurse is discharging a client diagnosed with a urinary tract infection. Which information should the nurse include in the discharge teaching? Select all that apply. Strain all urine. Limit fluid intake. Wipe from back to front. Take all antibiotics as prescribed. Avoid coffee, tea, and alcohol.

Take all antibiotics as prescribed. Avoid coffee, tea, and alcohol. Explanation: Fluid intake is encouraged to prevent stasis of urine. It is not necessary to strain the urine and wiping from front to back is proper technique to avoid infection. Coffee, tea, and alcohol are irritants and should be avoided. Antibiotics should be taken as prescribed to prevent resistance and reinfection.

A client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of wearing an appliance pouch only at bedtime. consuming a low-protein, high-fiber diet. taking only enteric-coated medications. increasing fluid intake to prevent dehydration.

increasing fluid intake to prevent dehydration. Explanation: Because stool forms in the large intestine, an ileostomy typically drains liquid waste. To avoid fluid loss through ileostomy drainage, the nurse should instruct the client to increase fluid intake. The nurse should teach the client to wear a collection appliance at all times because ileostomy drainage is incontinent, to avoid high-fiber foods because they may irritate the intestines, and to avoid enteric-coated medications because the body can't absorb them after an ileostomy.

A nurse is caring for an elderly client with a pressure ulcer on the sacrum. When teaching the client about dietary intake which foods should the nurse emphasize? whole grain products fruits and vegetables lean meats and low-fat milk legumes and cheese

lean meats and low-fat milk Explanation: Although the client should eat a balanced diet, including foods from all food groups, the diet should emphasize foods that supply complete protein, such as lean meats and low-fat milk. Protein helps build and repair body tissue, which promotes healing. Legumes provide incomplete protein. Cheese contains complete protein, but it also includes fat, which should be limited to 30% or less of caloric intake. Whole grain products supply incomplete proteins and carbohydrates. Fruits and vegetables provide mainly carbohydrates.

A client with iron-deficiency anemia is prescribed liquid iron supplements. The nurse evaluates the client's understanding of how to take this drug. Which statement indicates the client has adequate knowledge? "I'll dilute the medication and drink it with a straw." "I can use antidiarrheal drugs if I develop diarrhea." "I'll report any black stools to the health care provider." "I'll check my gums for any bleeding."

"I'll dilute the medication and drink it with a straw." Explanation: Liquid iron supplements should be diluted and taken through a straw to help decrease the likelihood of staining the teeth. Iron causes constipation, not diarrhea. It is normal for the client's stools to become dark during iron therapy. Iron does not cause bleeding gums.

The nurse is teaching a client how to self-administer insulin. Which statement by the client indicates a need for further teaching? "I don't have to aspirate." "Repeated injections in the same spot can cause scarring." "As long as I use the safety syringe, disposal is not a problem." "I should avoid injection sites that are inflamed or swollen."

"As long as I use the safety syringe, disposal is not a problem." Explanation: Regardless of safety devices on a syringe, the syringe should be disposed of in a sharp- or puncture-proof container. Swollen, inflamed, or scarred tissue will negatively impact absorption. Aspiration is not required when administered in the subcutaneous tissue.

The teaching plan for a client with rheumatoid arthritis includes rest promotion. What position of the involved joints should the nurse tell the client to avoid when at rest? elevating the affected joints lying in a prone position keeping all joints aligned maintaining the joints in a flexed position

maintaining the joints in a flexed position Explanation: Positions of flexion should be avoided to prevent loss of functional ability of affected joints. Proper body alignment during rest periods is encouraged to maintain correct muscle and joint placement. Lying in the prone position is encouraged to avoid further curvature of the spine and internal rotation of the shoulders.

A client with type 1 diabetes mellitus often skips their ordered dose of insulin. What priority information should the nurse give to this client regarding the omission of insulin doses? may cause hypoglycemic coma may lead to pancreatitis may lead to ketoacidosis may cause diabetes insipidus

may lead to ketoacidosis Explanation: A client who fails to regularly take insulin is at risk for hyperglycemia, which could lead to diabetic ketoacidosis. Hypoglycemia would not occur because the lack of insulin would lead to increased levels of sugar in the blood. A client with chronic pancreatitis may develop diabetes, but insulin-dependent diabetes mellitus does not lead to pancreatitis. Diabetes insipidus isn't caused by alteration in insulin levels.

During the discharge planning teaching process, a client who has been prescribed tranylcypromine states that they enjoy a beer or two in the evenings. Which is the nurse's most appropriate response? "You can only drink one beer every now and then when on this medication." "Beer contains wheat which must be avoided when taking this medication." "Beer contains tyramine which must be avoided when on this medication." "It is better that you drink beer than wine with this medication."

"Beer contains tyramine which must be avoided when on this medication." Explanation: A client taking a monoamine oxidase inhibitor antidepressant such as tranylcypromine should not consume foods containing tyramine. Such foods include beer, ale, Chianti wine, chicken livers, aged game meats, broad beans, aged cheeses, sour cream, avocados, yogurt, pickled herring, yeast extract, chocolate, excessive caffeine, vanilla, and soy sauce.

During a postpartum parenting class, a client tells the nurse that to save on the cost of formula, the client has switched her 6-month infant from formula to cow's milk. Which one of the following statements made by the nurse would be the best? "Cow's milk can be safely given to an infant older than one year of age." "Cow's milk has as lower amounts of protein. The infant will need additional amounts of milk to meet the infant's needs." "Cow's milk has higher amounts of iron, which could interfere with blood volume." "Powdered formula can be blended with cow's milk to supplement."

"Cow's milk can be safely given to an infant older than one year of age." Explanation: The quality and quantity of nutrients in cow's milk differs greatly from those of human milk, and cow's milk does not contain many of the various growth and immunological factors found in human milk. With regard to nutrient content, cow's milk contains great amounts of protein and minerals and smaller amounts of essential fatty acids than human milk. Cow's milk has low iron content, and the iron is poorly absorbed. To lower the risk of iron-deficiency anemia, cow's milk is not recommended before 12 months of age.

A middle-aged male client comes to the clinic for an evaluation of difficulty urinating and nocturia. His father died from prostate cancer. He asks the nurse what he can do to ensure early detection of this disease. What question will the nurse ask next? "Do you perform monthly testicular self-examinations?" "How many times a night do you get up to void?" "Have you had a transrectal ultrasound within the last 10 years?" "Do you have a digital rectal examination and prostate-specific antigen tests yearly?"

"Do you have a digital rectal examination and prostate-specific antigen tests yearly?" Explanation: Prostate-specific antigen (PSA) and digital rectal examinations, although not specific for prostate cancer, will indicate possible changes in the prostate gland. The transrectal ultrasound would be performed as a follow-up for an increased PSA and/or an enlarged prostate gland. Testicular exams will not reveal changes in the prostate. The client already told the nurse he has nocturia, so this question is gathering more information about symptoms, not detection of the disease.

It is the night before a client is to have a computed tomography (CT) scan of the head without contrast. What should the nurse tell the client to do to prepare for this test? "You may drink fluids until midnight, but after that, drink nothing until the scan is completed." "You must shampoo your hair tonight to remove all oil and dirt." "You will need to hold your head very still during the examination." "You will have some hair shaved to attach the small electrode to your scalp."

"You will need to hold your head very still during the examination." Explanation: The client will be asked to hold their head very still during the examination, which lasts about 30 to 60 minutes. In some instances, food and fluids may be withheld for 4 to 6 hours before the procedure if a contrast medium is used because the radiopaque substance sometimes causes nausea. There is no special preparation for a CT scan, so a shampoo the night before is not required. The client may drink fluids until 4 hours before the scan is scheduled. Electrodes are not used for a CT scan, nor is the head shaved.

The nurse is teaching two unlicensed assistive personnel (UAP) who are new to the inpatient unit about caring for a client who is suicidal. The nurse determines that additional teaching is needed when which statement is made? "All clients using razors must be supervised by staff." "I need to check the client precisely at 15-minute intervals." "Clients on one-to-one suicide precautions can never be left alone." "Documenting suicide checks is absolutely necessary."

"I need to check the client precisely at 15-minute intervals." Explanation: Clients on 15-minute suicide checks must be observed by a staff member every 15 minutes. However, the staff member must stagger the timing of the check so that the client cannot predict the precise time. The staff member could check the client at 10 minutes and then at 8 minutes, and so on, to protect the client from self-harm. The nurse would further explain the necessity of this procedure to help the staff understand its importance. Documenting that suicide checks have been done is absolutely necessary. Clients on one-to-one suicide precautions can never be left alone. All clients using razors must be supervised by staff.

A client is 2 hours postoperative after an appendectomy. The nurse recognizes a priority is to teach the client potential pulmonary postoperative complications. What action by the client demonstrates understanding of the teaching? incisional splinting to assist with pain management passive range of motion exercises with the physiotherapist continued bed rest for 24-48 hours postoperatively to protect the incision site diaphragmatic breathing and use of incentive spirometry 4-8 times an hour while awake

diaphragmatic breathing and use of incentive spirometry 4-8 times an hour while awake Explanation: Diaphragmatic breathing helps promote alveolar expansion and facilitates exchange of oxygen and carbon dioxide. Incisional splinting will not assist in preventing pulmonary risk; it will only address pain. Bed rest and passive range of motion are not correct.