A postpartum client who is bottle-feeding develops breast engorgement. Which is the best recommendation for the nurse to provide this client?

Avoid stimulation of the breasts and wear a tight bra.

Express a small amount of breast milk by hand.

Place warm packs on both breasts.

Take a prescribed analgesic and expose breasts to air.

Answer and Explanation

The Correct Answer is D

A.   Avoid stimulation of the breasts and wear a tight bra. Avoiding breast stimulation and wearing a tight bra may exacerbate breast engorgement by preventing milk expression and constricting blood flow. This recommendation is not appropriate for managing engorgement.
B.   Express a small amount of breast milk by hand. While hand expression can help relieve engorgement, it may also stimulate further milk production, leading to increased engorgement. This recommendation may not be sufficient for managing severe engorgement.
C.   Place warm packs on both breasts. Warm packs can increase blood flow and may provide temporary relief from discomfort, but they are not the most effective intervention for breast engorgement. Warmth can also increase inflammation and swelling in some cases.
D.   Take a prescribed analgesic and expose breasts to air. Taking a prescribed analgesic can help relieve pain associated with breast engorgement, while exposing the breasts to air allows for
cooling and may reduce swelling. This recommendation addresses both pain relief and management of engorgement symptoms.

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Correct Answer is []

Explanation

- Potential Condition:

Stage 2 pressure injury

- Actions to Take:

C. Clean the area and dry carefully: Proper wound care involves cleaning the area to prevent infection and promote healing. Cleaning the erythematous area on the left heel and ensuring
it is dry can help prevent further skin breakdown and promote healing.

B. Hold the hydrochlorothiazide: Hydrochlorothiazide is a diuretic that can increase urine output and potentially lead to dehydration, which may exacerbate the client's condition. Holding the medication temporarily can help prevent further fluid loss and dehydration, which is crucial for wound healing.

- Parameters to Monitor:

B. Skin color: Monitoring the skin color around the erythematous area on the left heel can help assess tissue perfusion and identify any signs of deterioration or improvement in the wound condition.
D. Fluid balance: Monitoring the client's fluid balance, including intake and output, is essential for assessing hydration status and ensuring adequate tissue perfusion, which is vital for wound healing and overall patient well-being.

A. Assist the client with clarifying values about end-of-life care options. B. Ask the client how often episodes of sundowning are experienced. C. Request to have the client lie as still as possible for the assessment. D. Question the client about the frequency of falls in recent months.

Correct Answer is D

Explanation

A. This action pertains more to discussions about advance care planning and end-of-life preferences, which may be important but are not directly related to assessing the client's functional status.

B. Episodes of sundowning are associated with changes in behavior, confusion, and agitation in some individuals with dementia, particularly in the late afternoon or evening. While important to assess in certain contexts, it is not directly related to evaluating the client's physical strength and mobility.

C. Asking the client to lie still does not provide information about their functional status or ability to perform activities of daily living.

D. This is the most appropriate action because it directly addresses the client's reported decreased strength and assesses the impact on their functional ability. Falls are a common consequence of reduced strength and mobility in older adults and can provide valuable information about the client's current physical function and safety.

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A postpartum client who is bottle-feeding develops breast engorgement. Which is the best recommendation for the nurse to provide this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Correct Answer is []

Explanation

An older adult client arrives at the clinic reporting decreased strength in knees and in handgrips. Which action should the nurse include in a functional assessment of the client?

Correct Answer is D

Explanation

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