A nurse is caring for a client who is 24 hr postpartum and is breastfeeding her newborn. The client asks the nurse to warm up seaweed soup that the client's partner brought for her. Which of the following responses should the nurse make?
“The hospital food is more nutritious for you”
“Of course, I will heat that up for you."
"Why are you eating seaweed soup?”
“Does the doctor know that you are eating that?"
The Correct Answer is B
Rationale:
A. “The hospital food is more nutritious for you”: This response dismisses the client’s cultural preferences and assumes hospital food is superior without acknowledging personal or traditional choices, which may negatively affect rapport and trust.
B. “Of course, I will heat that up for you.” This response respects the client’s cultural beliefs and supports individualized postpartum care. Seaweed soup is a traditional food in some cultures believed to aid in postpartum recovery and milk production.
C. “Why are you eating seaweed soup?” Asking this without sensitivity can come off as judgmental or culturally insensitive. The client may feel criticized or misunderstood, even if the nurse is simply curious.
D. “Does the doctor know that you are eating that?” This implies that the food might be unsafe or needs medical approval, which can be perceived as disrespectful or unnecessary unless there’s a clinical reason for concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Apply direct pressure to the wound with thick dressing material: Direct pressure is the first-line intervention for controlling active external bleeding. Applying firm pressure with thick, sterile dressing helps tamponade the bleeding vessel and minimizes blood loss while awaiting further treatment.
B. Apply a transparent dressing to the wound: Transparent dressings are used for minor wounds or IV sites, not for managing active bleeding. They do not provide the necessary compression to control hemorrhage from a deep or penetrating injury.
C. Irrigate the wound with sterile water: Wound irrigation is appropriate for cleaning minor wounds or after bleeding is controlled. Irrigating during active bleeding can delay hemostasis and increase blood loss.
D. Tie a tourniquet around the leg distal to the wound: A tourniquet, if necessary, must be placed proximal not distal to the bleeding site to effectively restrict arterial flow. Distal placement worsens bleeding and can compromise tissue perfusion unnecessarily.
Correct Answer is D
Explanation
Rationale:
A. Insert an indwelling urinary catheter: While important for monitoring urine output and renal perfusion, catheter insertion is not the immediate priority in a trauma situation. It should be done after vascular access is secured and life-threatening conditions are addressed.
B. Administer packed RBCs: Blood transfusion is critical for managing hemorrhagic shock, but it cannot be initiated until a large-bore IV is placed. Vascular access is necessary before any fluid or blood product administration.
C. Obtain a specimen for ABG analysis: ABGs provide valuable data on oxygenation and acid-base balance but are diagnostic rather than life-sustaining. This step is less urgent than establishing IV access for fluid resuscitation or transfusion.
D. Place a large-bore IV catheter in an upper extremity: In trauma care, rapid IV access is the top priority to allow fluid and blood product resuscitation. A large-bore catheter ensures high-volume administration, which is essential in potential hemorrhagic shock.
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