A nurse is caring for a client who has constipation and is bearing down to have a bowel movement. The nurse should monitor the client for which of the following?

Decreased heart rate

Increased respirations

Increased temperature

Decreased exhaled carbon dioxide

Answer and Explanation

The Correct Answer is A

A. Decreased heart rate: Bearing down (Valsalva maneuver) can stimulate the vagus nerve, leading to a decrease in heart rate.

B. Increased respirations: Respirations may not increase during the Valsalva maneuver but rather may temporarily decrease or become irregular.

C. Increased temperature: No direct link exists between the Valsalva maneuver and temperature changes.

D. Decreased exhaled carbon dioxide: Valsalva may lead to transient changes in exhaled CO2, but decreased heart rate is the more immediate concern.

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Correct Answer is A

Explanation

A. The nurse who delegates a task remains accountable for ensuring that it is completed safely and correctly, even though the delegatee performs the task.

B. There are five rights of delegation: the right task, circumstance, person, direction/communication, and supervision/evaluation.

C. While nurse managers may provide general oversight, individual nurses are responsible for delegating tasks during their shift based on client needs and team resources.

D. The delegatee has a responsibility to seek clarification or decline tasks they are not competent to perform, ensuring safety and ethical practice.

A. "During hospice care services, the client can receive their IV chemotherapy medications.” B. "Hospice care services keep the family updated on the client's condition.” C. “During hospice care services, the caregiver receives a break from caring for the client for personal time." D. “Hospice care services are initiated when the client has less than 2 years to five.”

Correct Answer is B

Explanation

A. During hospice care services, the client can receive their IV chemotherapy medications: Hospice care focuses on comfort and palliative care, not curative treatments like chemotherapy.

B. Hospice care services keep the family updated on the client's condition: One of the key components of hospice care is ensuring the family is informed and supported.

C. During hospice care services, the caregiver receives a break from caring for the client for personal time: While respite care is available, it is not the central focus of hospice care.

D. Hospice care services are initiated when the client has less than 2 years to live: Hospice care is typically for clients with a prognosis of 6 months or less to live, not 2 years.

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A nurse is caring for a client who has constipation and is bearing down to have a bowel movement. The nurse should monitor the client for which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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