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Questions 164

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Question 1 of 5

A nurse is teaching a class for new parents at a local community center. The nurse would stress that what is most hazardous for an 8 month-old child?

Correct Answer: D

Rationale: Eating peanuts. Asphyxiation due to foreign materials in the respiratory tract is the leading cause of death in children younger than 6 years of age.

Question 2 of 5

The home care nurse is observing the client's spouse performing a colostomy irrigation. Which action needs correction?

Correct Answer: D

Rationale: Petroleum jelly is not suitable for lubricating colostomy irrigation catheters, as it may degrade materials or harbor bacteria; water-soluble lubricant is preferred. The height, volume, and position are appropriate.

Question 3 of 5

The nurse is caring for a client with type 1 diabetes mellitus who is reporting abdominal pain and weakness. The client has a fruity odor to the breath and rapid, deep respirations. Which of the following actions should the nurse take? Select all that apply.

Correct Answer: B,C,D,E

Rationale: Symptoms suggest diabetic ketoacidosis (DK
A). Checking glucose confirms hyperglycemia, cardiac monitoring detects arrhythmias from electrolyte imbalances, IV insulin corrects hyperglycemia, and saline bolus addresses dehydration. Breathing into a paper bag is for hyperventilation from anxiety, not DKA.

Question 4 of 5

An adult client who is ambulating in the corridor with the nurse becomes dizzy and faint. What should the nurse do at this time?

Correct Answer: C

Rationale: Guiding the client to a chair prevents falls and ensures safety during dizziness. Head positioning, seeking help, or faster walking are unsafe or impractical.

Question 5 of 5

The clinic nurse has contributed to the teaching plan for the following 6 clients. The nurse reinforces the teaching by instructing which client to avoid the Valsalva maneuver when defecating? Select all that apply.

Correct Answer: A,C,E,F

Rationale: The Valsalva maneuver increases intracranial pressure (head injury), cardiac strain (post-MI), intra-abdominal pressure (portal hypertension), and intraocular pressure (post-cataract surgery), risking complications. Mammoplasty and pancreatic cancer have less direct risks.

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