A nurse is teaching about how to suppress lactation with a client who is postpartum and bottle-feeding her newborn.
Which of the following instructions should the nurse include in the teaching?

"You should limit your fluid intake to 1 liter per day.”

"You should manually express milk when engorgement occurs.”

"You should wear a snug-fitting bra continuously for 72 hours.”

"You should apply moist heat to your breasts four times per day.”

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Limiting fluid intake to 1 liter per day can lead to dehydration and other health complications. It is important for the client to maintain adequate hydration, especially postpartum. This option is incorrect and potentially harmful.

Choice B rationale:

Manual expression of milk can help relieve engorgement without stimulating further milk production. This method allows the client to express milk as needed. However, it can be done even before engorgment occurs

Choice C rationale:

Wearing a snug-fitting bra can provide support and comfort.

Choice D rationale:

Applying moist heat to the breasts can stimulate milk production and relieve engorgement. However, in this case, the client wants to suppress lactation. Therefore, this option is not appropriate and may have the opposite effect of increasing milk production.

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Correct Answer is D

Explanation

A: Incorrect. Hospital-based hospice care is not a service provided by PACE, which is a program that offers comprehensive medical and social services to eligible older adults who wish to remain in their own homes and communities.
D: Correct. Adult day care services are part of the PACE program, which helps older adults maintain their independence and quality of life by providing socialization, supervision, and assistance with activities of daily living.
C: Incorrect. Telehealth for pacemaker diagnostics is not a specific service offered by PACE, which provides primary care, specialty care, prescription drugs, home health care, personal care, transportation, and other services as needed.
B: Incorrect. Transfer to a skilled care facility is not a goal of PACE, which aims to prevent or delay institutionalization by providing coordinated care and support to older adults with chronic conditions and functional limitations.

A. Hang the transfusion with dextrose 5% in 0.9% sodium chloride. B. Infuse the transfusion over 5 hr. C. Use a 20-gauge IV catheter to transfuse the blood. D. Monitor vital signs every hour throughout the transfusion.

Correct Answer is D

Explanation

Choice A rationale:

Hanging the transfusion with dextrose 5% in 0.9% sodium chloride is incorrect. Packed red blood cells (PRBCs) are transfused with normal saline (0.9% sodium chloride) and not with dextrose-containing solutions. Using dextrose can cause the red blood cells to hemolyze.

Choice B rationale:

Infusing the transfusion over 5 hours is incorrect. PRBC transfusions are typically administered over 2-4 hours, not 5 hours. Infusing the blood too slowly may cause the patient discomfort and may also increase the risk of bacterial growth in the blood product.

Choice C rationale:

Using a 20-gauge IV catheter to transfuse the blood is incorrect. While a 20-gauge IV catheter is suitable for most blood transfusions, it may not be appropriate for older adults or patients with fragile veins. A smaller gauge, such as 22 or 24, might be more suitable to prevent phlebitis and ensure a steady flow without damaging the blood cells.

Choice D rationale:

Monitoring vital signs every hour throughout the transfusion is the correct action. During a blood transfusion, it's crucial to monitor the patient's vital signs frequently to detect any adverse reactions promptly. Vital signs, including blood pressure, heart rate, respiratory rate, and temperature, should be assessed before the transfusion, 15 minutes after starting the transfusion, and then hourly thereafter. This vigilant monitoring helps in identifying potential transfusion reactions, such as fever, chills, or hypotension, allowing for immediate intervention if needed.

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A nurse is teaching about how to suppress lactation with a client who is postpartum and bottle-feeding her newborn. Which of the following instructions should the nurse include in the teaching?

Nursing Test Bank

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A nurse is teaching about how to suppress lactation with a client who is postpartum and bottle-feeding her newborn.
Which of the following instructions should the nurse include in the teaching?