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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

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 3 of 5

The licensed practical nurse (LPN) assigns the ambulation of a client to unlicensed assistive personnel (UAP). The LPN observes UAP placing the clients Foley bag on the IV pole at the level of the client's chest during client ambulation down the length of the hallway. What action should the LPN take initially?

Correct Answer: A

Rationale: The Foley bag must be kept below bladder level to prevent urine backflow and infection risk. Immediate correction and private education ensure safety and learning without delay.

Question 4 of 5

A client with ascites due to cirrhosis has increasing shortness of breath and abdominal pain and is scheduled for paracentesis. Which of the following nursing actions should be implemented prior to the procedure? Select all that apply.

Correct Answer: A,D,E

Rationale: Informed consent ensures understanding, emptying the bladder prevents injury during needle insertion, and baseline vital signs/weight monitor fluid shifts. Reverse Trendelenburg is inappropriate; upright positioning is typical. NPO status isn't required for paracentesis.

Question 5 of 5

The nurse is observing a 3-year-old client for expected developmental milestones. It would require follow-up if the client cannot

Correct Answer: B

Rationale: Copying a square is expected by age 4-5, not 3, indicating a fine motor delay requiring follow-up. Catching a ball, eating with a spoon, and hopping are age-appropriate or slightly advanced for a 3-year-old.

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