NCLEX-RN
The nurse is caring for expectant and new mothers. The nurse would encourage breastfeeding for the client who is: human immunodeficiency virus (HIV) positive. being treated for active tuberculosis (TB). diagnosed with mastitis. currently prescribed lithium.
A client with mastitis can continue to breastfeed, provided she is not taking antibiotics that are contraindicated in breastfeeding. A mother who has HIV or active TB is strongly discouraged from breastfeeding because of concerns about transmitting the infection to the neonate. Lithium, chemotherapy medications, and amiodarone are some of the few medications that are absolute contraindications to breastfeeding.
Urinary tract infection (UTI) is a potential problem after spinal cord injury. To prevent an UTI, the nurse should encourage the client to: drink a glass of citrus fruit juice at every meal. drink at least 2,000 mL of fluid daily. add extra protein to the daily diet. wash hands frequently.
As soon as the client's vasomotor status stabilizes and is not susceptible to fluid volume overload, it is essential to drink at least 2,000 mL of fluid daily. Increased fluid intake helps flush out bacteria and prevents urinary stasis.Citrus juices are not encouraged. They can promote a urinary tract infection because they are alkaline-forming. Most citrus fruits are not metabolized as acids in the body.Extra protein does not decrease the potential for a urinary tract infection.While washing hands frequently is an appropriate health habit, UTIs in clients with spinal cord injuries primarily are caused by urinary stasis, and not prevented by handwashing
A nurse has been providing care to a client in labor for the past 9 hours. The partner remains at the bedside while the laboring client is sleeping with the epidural block in situ. Which is the most appropriate nursing action? Encourage the partner to take a break for 1 hour. Instruct the partner to contact another support person take their place because the partner is exhausted. Offer to remain with the client while the partner takes a short break. Suggest that the partner goes home to sleep for a few hours.
It is possible that the partner is reluctant to leave the client alone during this time. It is appropriate, if possible, for the nurse to offer to stay with the client while the partner goes for a break. The partner will be able to take a break and know that the client is not alone at the time. The nurse should not direct or instruct the partner to go home or to have another support person come in. It is important that the nurse is respectful of client and family desires.
When performing Leopold's maneuvers, which action would the nurse ask the client to perform to ensure optimal comfort and accuracy? breathing deeply for 1 minute emptying her bladder drinking a full glass of water lying on her left side
Leopold's maneuvers involve abdominal palpation. The client should empty her bladder before the nurse palpates the abdomen. Doing so increases the client's comfort and makes palpation more accurate. Although breathing deeply may help to relax the client, it has no effect on the accuracy of the results of Leopold's maneuvers. The client does not need to drink a full glass of water before the examination. The client should be lying in a supine position with the head slightly elevated for greater comfort and with the knees drawn up slightly.
The parents of a 5-year-old child who stutters ask the nurse how to best manage the child's language skills. What recommendation(s) will the nurse make? Select all that apply. Discuss the speech problems with the child. Resist the urge to interrupt the child or fill in words. Repeatedly instruct the child to speak slowly. Ensure that family members don't draw attention to the stutter. Seek opportunities for the child to speak outside the home.
Resisting the urge to interrupt the child and preventing family members from drawing attention to the stutter are ways to acknowledge the child's efforts and make the child feel supported. The other options may make the child more conscious of the speech problems and may aggravate the situation.
What should the nurse teach the client with neutropenia to avoid? using suppositories or enemas using a high-efficiency particulate air (HEPA) filter mask performing perianal care after every bowel movement performing oral care after every meal
The neutropenic client is at risk for infection, especially bacterial infection of the respiratory and gastrointestinal tracts. Breaks in the mucous membranes, such as those that could be caused by the insertion of a suppository or enema tube, would be a break in the first line of the body's defense and a direct port of entry for infection. The client with neutropenia is encouraged to wear a HEPA filter mask and to use an incentive spirometer for pulmonary hygiene. The client needs to know the importance of completing meticulous total body hygiene daily, including perianal care after every bowel movement, to decrease the flora at normal body orifices. The client also needs to know the importance of performing oral care after every meal and every 4 hours while the client is awake to decrease the bacterial buildup in the oropharynx.
