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Questions 164

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Question 1 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.

Question 2 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 3 of 5

After assisting a client with a lower gastrointestinal bleed back to bed, the nurse finds approximately 600 mL of frank red blood in the toilet. The client is pale and diaphoretic and reports dizziness. Which action should the nurse perform first?

Correct Answer: C

Rationale: Significant bleeding (600 mL), pallor, diaphoresis, and dizziness suggest hypovolemia. Lowering the head of the bed improves cerebral perfusion, stabilizing the client. Notification, labs, and documentation follow stabilization.

Question 4 of 5

Which statements made by the client demonstrate a correct understanding of the home care of an ascending colostomy? Select all that apply.

Correct Answer: A,C

Rationale: Enteric-coated medications may not dissolve properly in an ascending colostomy due to shorter intestinal transit time, requiring provider consultation. Limiting odor-causing foods like broccoli helps manage odor. Irrigation is typically for descending/sigmoid colostomies, not ascending. Fluid intake should be adequate (not restricted), and pouches should be emptied when one-third to half full to prevent leaks.

Question 5 of 5

A staff nurse complains to the nurse manager that an unlicensed assistive personnel (UAP) consistently leaves the work area untidy and does not restock supplies. The best initial response by the nurse manager is which of these statements?

Correct Answer: C

Rationale: Helping staff manage conflict is part of the manager's role. It is appropriate to urge the nurse to confront the other staff member to work out problems without a manager's intervention when possible.

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