A postpartum client who is breastfeeding expresses concerns about breast engorgement and discomfort. What nursing intervention should be prioritized to alleviate symptoms?

Correct Answer: A

Rationale: The most appropriate nursing intervention to alleviate breast engorgement and discomfort in a breastfeeding client is to encourage frequent breastfeeding or pumping sessions. Engorgement occurs when the breasts become overly full of milk, causing them to become swollen, firm, and painful. By ensuring that the baby breastfeeds frequently, the client can effectively empty the breasts, which helps to relieve engorgement and discomfort. Encouraging the client to breastfeed on demand and ensuring proper latching can help prevent further engorgement issues. Pumping can also be useful if the baby is unable to feed directly from the breast or to relieve engorgement between feedings. This intervention addresses the root cause of the problem and promotes the client's comfort and breastfeeding success. Applying cold packs, using a supportive bra or breast binder, and administering oral analgesics may provide some relief for discomfort but do not address the underlying issue of engorgement.

Correct Answer: B

Rationale: Assisting the client to a seated position on the toilet should be implemented first. This position promotes relaxation of the pelvic floor muscles and can help facilitate urinary elimination. It is a non-invasive and least intrusive intervention compared to performing intermittent catheterization or administering diuretic medication. Encouraging the client to drink plenty of fluids is important for promoting overall urinary function, but in this case, the priority is to aid the client in attempting to void first.

Correct Answer: B

Rationale: In an educational program conducted by a nurse, it is crucial to involve the patient, their family, and significant others. This approach ensures holistic care by considering the patient's psychosocial environment, family dynamics, and support system. Including these individuals in the educational program fosters collaboration, strengthens the patient-nurse relationship, and equips family members with the knowledge and skills needed to provide optimal care at home. Furthermore, involving the patient's support system can enhance adherence to treatment plans and contribute to better health outcomes. Therefore, the presence and cooperation of the patient, family, and significant others are essential elements of a successful educational program led by a nurse.

Correct Answer: D

Rationale: Transcription errors are typically associated with issues such as illegible handwriting, misinterpretation of directions, and the use of unapproved abbreviations. However, the wrong route of medication administration is not specifically related to transcription errors but rather falls under the category of medication administration errors. Administering medication via the wrong route can lead to serious consequences for the patient and is a separate issue from the act of transcribing doctor's orders.

Correct Answer: B

Rationale: The correct action for the nurse to ensure proper insertion technique during a urinary catheterization is to use aseptic technique and sterile equipment. This is crucial in preventing infections and ensuring patient safety. Aseptic technique involves maintaining cleanliness and preventing the introduction of harmful microorganisms during invasive procedures like catheterization. Using sterile equipment helps minimize the risk of introducing bacteria into the urinary tract, which could lead to a urinary tract infection (UTI). Therefore, it is essential that the nurse follows strict infection control protocols and uses sterile equipment to maintain patient safety and well-being during the catheterization procedure.

Correct Answer: A

Rationale: The patient with a history of COPD presenting with increased dyspnea, cough productive of purulent sputum, and coarse crackles on auscultation is most likely experiencing an acute exacerbation of COPD. Acute exacerbations in COPD are defined as sustained worsening of the patient's respiratory symptoms beyond normal day-to-day variations, leading to a change in medication. Common triggers for exacerbations include respiratory infections, air pollution, and non-compliance with medications.

Correct Answer: A

Rationale: Macrophages are the primary cells responsible for producing tumor necrosis factor-alpha (TNF-α) during the acute phase response. TNF-α is a pro-inflammatory cytokine that plays a critical role in initiating and propagating the inflammatory response. Macrophages secrete TNF-α in response to infection, injury, or other inflammatory stimuli, contributing to the recruitment of immune cells and the activation of additional inflammatory pathways. In the context of the acute phase response, macrophages are key mediators of the immune response and play a crucial role in host defense mechanisms.

Correct Answer: B

Rationale: Supplying the patient with paper tissues to use when touching doorknobs is the most appropriate response in this situation. This action acknowledges and respects the patient's anxiety while providing a practical solution to help her cope. Forcing her to touch doorknobs or discouraging her concerns would not address the underlying anxiety and may lead to increased distress. Encouraging her to scrub doorknobs with a strong antiseptic is not necessary and may exacerbate her anxiety. Explaining that her concerns are part of her illness may invalidate her feelings and is not a constructive way to address the situation. Supplying her with paper tissues allows her to feel more comfortable while still being able to navigate her daily activities.

Correct Answer: B

Rationale: The statement provided clearly outlines the expectation regarding the dress code in the facility. By explicitly mentioning that wearing blue jeans while on duty is not included in the dress code, the individual is being informed about a specific expectation they are expected to adhere to. Stating expectations is a crucial step in giving constructive criticism as it sets a clear standard for behavior or performance. In this case, by mentioning the dress code policy, it helps guide the individual on what is acceptable and what is not when it comes to attire while at work.