Questions 150

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Question 1 of 5

On the first postpartum day, the nurse is caring for a primiparous client who has recently emigrated from Japan to the United States and speaks only a little English. The nurse observes that the client has been bottle-feeding her neonate on occasion, but most of the neonatal care is being performed by the client's mother-in-law. Which of the following actions would be most appropriate?

Correct Answer: C

Rationale: Assessing whether the mother-in-law's involvement is a cultural practice respects the client's background and avoids misjudging normal family dynamics.

Question 2 of 5

A client's laboratory test results reveal a decrease in both serum transferrin and total iron-binding capacity (TIBC). Which disorder is the most likely cause of the client's anemia?

Correct Answer: B

Rationale: Malnutrition can cause reductions in the serum transferrin and the TIBC. Infection is an unrelated option. Iron-deficiency anemia is usually characterized by decreased iron-binding capacity but increased transferrin levels. Additionally, in clinical practice, the hemoglobin level is routinely used to detect iron-deficiency anemia. Sickle cell anemia is diagnosed by determining that the client has hemoglobin S.

Question 3 of 5

A client with a history of chronic obstructive pulmonary disease (COPD) is prescribed tiotropium (Spiriva). The nurse should instruct the client to:

Correct Answer: B

Rationale: Rinsing the mouth after tiotropium inhalation prevents oral thrush.

Question 4 of 5

Your client has a doctor's order for the antihistamine medication diphenhydramine for sleep. What should you do?

Correct Answer: D

Rationale: Diphenhydramine (Benadryl) is commonly used off-label for sleep due to its sedative effects, making it an appropriate choice if ordered for this purpose.

Question 5 of 5

The nurse is discharging a client who has been hospitalized for preterm labor. The client needs further instruction when she says:

Correct Answer: D

Rationale: Clients with preterm labor should get out of the car every 1-2 hours to promote circulation and prevent complications, not every 4 hours, indicating a need for further instruction.

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