During defecation, the client experiences decreased cardiac output related to the Valsalva maneuver. After the Valsalva maneuver, the nurse assesses the client's vital signs and expects to observe which of the following?

a slowing of client's heart rate

a decrease in the client's blood pressure

an increase in the client's respiratory rate

a decrease in the client's respiratory rate

Answer and Explanation

The Correct Answer is A

a) A slowing of the client's heart rate: The Valsalva maneuver (straining during defecation) can cause a transient increase in intra-abdominal pressure, which triggers vagal stimulation, leading to a slowing of the heart rate (bradycardia).

b) A decrease in the client's blood pressure: The Valsalva maneuver may initially cause an increase in blood pressure, followed by a drop after the maneuver is released. The immediate effect is a slowing of the heart rate, not a decrease in blood pressure.

c) An increase in the client's respiratory rate: The Valsalva maneuver typically causes a temporary decrease in respiratory rate due to the strain on the body.

d) A decrease in the client's respiratory rate: The Valsalva maneuver does not typically result in a significant decrease in respiratory rate. Instead, it is more likely to cause a brief alteration in heart rate and blood pressure.

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Correct Answer is D

Explanation

a) Respiratory Decompression: "Respiratory Decompression" is not a term used in ABG interpretation.

b) Respiratory Alkalosis: Respiratory alkalosis is characterized by a pH greater than 7.45 and a PaCO2 less than 35 mm Hg. In this case, the pH is low (7.31), and the PaCO2 is elevated, which is not consistent with respiratory alkalosis.

c) Respiratory PH: "Respiratory PH" is not a proper ABG term.

d) Respiratory Acidosis: The pH is 7.31, which is acidotic (normal range is 7.35-7.45). The PaCO2 is 50 mm Hg (elevated), indicating that the cause of the acidosis is respiratory in nature, as the kidneys have not yet compensated with HCO3 (bicarbonate).

A. Kinking the catheter tubing to obtain a urine specimen B. Emptying the drainage bag every 8 hours or when half full C. Failing to secure the catheter tubing to the patient's thigh D. Placing the drainage bag on the side rail of the patient's bed

Correct Answer is D

Explanation

a) Kinking the catheter tubing to obtain a urine specimen: Kinking the catheter tubing can cause backflow of urine, increasing the risk of infection, but it is not as significant a risk factor as improper drainage bag positioning.

b) Emptying the drainage bag every 8 hours or when half full: Properly emptying the drainage bag regularly reduces the risk of infection, as it prevents overfilling and backflow. This practice is usually part of proper care.

c) Failing to secure the catheter tubing to the patient's thigh: Securing the tubing to the thigh is important for preventing pulling or tension, but it’s not as significant in terms of infection risk as the positioning of the drainage bag.

d) Placing the drainage bag on the side rail of the patient's bed: This significantly increases the risk of urinary tract infections (UTIs) as it can cause the urine to flow back into the bladder, a condition called "reflux." The drainage bag should always be kept below the level of the bladder.

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During defecation, the client experiences decreased cardiac output related to the Valsalva maneuver. After the Valsalva maneuver, the nurse assesses the client's vital signs and expects to observe which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Arterial blood gases (ABGs) have been drawn on the client. The nurse reviews the results. pH is 7.31 PaCO2 50 mm Hg (6.65 kPa) HCO3 26 mEq/L (26 mmol/L) How will the nurse interpret these ABG results.

Correct Answer is D

Explanation

The nurse knows that which indwelling catheter procedure places the patient at greatest risk of acquiring a urinary tract infection?

Correct Answer is D

Explanation

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