A postpartum client expresses concerns about breastfeeding and worries about inadequate milk supply. What nursing intervention should be prioritized to address the client's concerns?

Correct Answer: A

Rationale: Assessing the infant's latch and feeding effectiveness should be prioritized as the initial nursing intervention to address the client's concerns about inadequate milk supply. Poor latch can lead to ineffective milk removal, which may result in decreased milk production. By ensuring the infant is latching correctly and effectively transferring milk, the client's milk supply can be optimized. Education about techniques to increase milk production can be provided following the assessment of feeding effectiveness. Referring to a lactation consultant may be necessary for further evaluation and support if issues persist despite correcting the latch. Supplemental formula feedings should be recommended as a last resort after all other interventions have been attempted and if there are concerns about inadequate nutrition for the infant.

Correct Answer: C

Rationale: NSAIDs are known to increase the risk of gastrointestinal complications, particularly gastrointestinal bleeding, ulcers, and perforation. This risk is higher in patients who are elderly, have a history of peptic ulcer disease, are taking high doses of NSAIDs, or are using them for a prolonged period. It is important for the nurse to closely monitor the patient for signs and symptoms of gastrointestinal bleeding, such as abdominal pain, black or tarry stools, vomiting blood, and anemia. Prompt identification and management of these complications are essential to prevent serious consequences. Monitoring for gastrointestinal adverse effects is crucial when a patient is prescribed NSAIDs for managing conditions like osteoarthritis.

Correct Answer: C

Rationale: Hypokalemia (low levels of potassium) increases the risk of digoxin toxicity. This is because digoxin competes with potassium for binding sites on the sodium-potassium ATPase pump in the cell membrane. When potassium levels are low, there is an increased binding of digoxin to these pumps, leading to enhanced entry of calcium into the cells. This can result in an increased intracellular calcium concentration, leading to digoxin toxicity and potential cardiac arrhythmias. Therefore, monitoring and correcting potassium levels is crucial in patients prescribed digoxin to reduce the risk of toxicity.

Correct Answer: C

Rationale: Cleaning the inner cannula daily helps prevent the accumulation of secretions and debris, which can lead to blockages and infections. It is an essential aspect of tracheostomy care to maintain the patency of the airway and prevent complications. Caregivers should be taught how to safely remove, clean, and reinsert the inner cannula as part of routine tracheostomy care.

Correct Answer: C

Rationale: The suicide of her mother is the most probable historical data that led to post-traumatic stress disorder. Experiencing the suicide of a close family member, especially a parent, can be an extremely traumatic event that can have long-lasting psychological effects. Witnessing or dealing with such a tragic loss can lead to feelings of helplessness, depression, guilt, and intense emotional distress, all of which are common in individuals with post-traumatic stress disorder (PTSD). This significant and distressing event could have a profound impact on the individual's mental health and well-being, contributing to the development of PTSD symptoms such as intrusive memories, avoidance behaviors, negative mood alterations, and changes in arousal or reactivity.

Correct Answer: B

Rationale: When a patient is in skin traction, the constant pressure and rubbing against the skin from the traction device can lead to skin breakdown. Therefore, assessing for signs of skin breakdown, such as redness, irritation, or pressure injuries, is crucial to prevent complications and ensure the patient's comfort and safety. Prompt identification and intervention for any skin issues can prevent further damage and promote healing, making this the priority intervention for quality nursing care in skin traction. While monitoring for signs of infection, urinary incontinence, and bowel sounds are important, skin breakdown poses a more immediate threat to the patient's well-being in this scenario.

Correct Answer: C

Rationale: The nurse's best approach to address the patient's confusion about their medication regimen is to use a teach-back method to assess understanding and clarify any misconceptions. This method involves the nurse asking the patient to explain in their own words how they will take their medications, what each medication is for, and any potential side effects they should watch for. By using the teach-back method, the nurse can confirm the patient's comprehension and correct any misunderstandings in a supportive and non-judgmental manner. This approach promotes patient education, empowerment, and adherence to the medication regimen. Providing written instructions alone (Choice A) may not be sufficient if the patient has difficulty reading or understanding written information. Explaining the medication regimen using complex medical terminology (Choice B) can further confuse the patient, making it harder for them to grasp the information. Dismissing the patient's concerns and reassuring them that the medication is safe (Choice D) does not address the root of the issue and

Correct Answer: B

Rationale: Adenomyosis is a condition characterized by the presence of endometrial tissue within the myometrium (muscle wall) of the uterus. It can present with symptoms such as cyclic pelvic pain, dysmenorrhea (painful periods), and infertility. On pelvic examination, the uterus may be retroverted (tilted backward) and enlarged due to the presence of adenomyotic nodules within the uterine muscle. Adenomyosis can also cause heavy menstrual bleeding (menorrhagia). Endometriosis, on the other hand, involves the presence of endometrial tissue outside the uterus and can cause similar symptoms but is less likely to result in uterine enlargement or retroversion. Leiomyomas (uterine fibroids) are benign tumors of the uterine muscle and can also cause pelvic pain and abnormal uterine enlargement but are less likely to be associated with dysmenorrhea and infertility

Correct Answer: B

Rationale: Medical records are typically required to be retained for a certain period of time as mandated by legal and regulatory requirements. The retention period for medical records is generally between 5 to 10 years, depending on the jurisdiction and specific regulations governing healthcare facilities. Keeping medical records for this duration ensures that they are available for reference, audits, legal purposes, and continuity of care for patients. Storing medical records for an adequate length of time also helps in ensuring continuity of care and tracking patients' medical history over time, which is crucial for quality healthcare delivery. Therefore, storing charts in the Medical Records or storage room for at least 5-10 years aligns with standard practices in healthcare compliance and patient care.