Nursing Elites

1. The nurse is told in report that the client has aortic stenosis. Which anatomical position should the nurse auscultate to assess the murmur?

• A. Second intercostal space, right sternal border
• B. Erb’s point
• C. Second intercostal space, left sternal border
• D. Fourth intercostal space, left sternal border

Correct answer: A

Rationale: The correct anatomical position for auscultating the murmur of aortic stenosis is the second intercostal space, right sternal border. This is where the aortic valve is best auscultated, and the murmur of aortic stenosis is heard most clearly. Choices B, C, and D are incorrect as the murmur of aortic stenosis is best heard at the second intercostal space on the right side of the sternum.

2. The system used at the division level and forward comprises six basic modules. Which module is composed of practical nurses, medical specialists, and equipment to provide medical support for minimal care patients?

• A. Treatment squad
• B. Patient Holding Squad
• C. Area Support Squad
• D. Surgical Squad

Correct answer: B

Rationale: The Patient Holding Squad is the module that is composed of practical nurses, medical specialists, and equipment to provide medical support for minimal care patients. This squad focuses on providing necessary care for patients who require minimal attention. Choices A, C, and D are incorrect because they do not specifically cater to the needs of minimal care patients. The Treatment Squad may involve more intensive procedures, the Area Support Squad focuses on broader support functions, and the Surgical Squad is specialized for surgical interventions.

3. What intervention would be most important for the nurse to implement for the client with a left nephrectomy?

• A. Assess the intravenous fluids for rate and volume
• B. Change the surgical dressing daily at the same time
• C. Monitor the client’s medication levels daily
• D. Monitor the percentage of each meal eaten

Correct answer: A

Rationale: The correct answer is A: Assess the intravenous fluids for rate and volume. After a nephrectomy, monitoring intravenous fluids is crucial to ensure proper hydration and kidney function. Choice B is incorrect because changing the surgical dressing daily is important but not the most critical intervention. Choice C is incorrect as monitoring medication levels daily may be necessary but is not the priority after a nephrectomy. Choice D is irrelevant to the immediate postoperative care needed after a nephrectomy.

4. The client diagnosed with diabetes mellitus type 2 is admitted to the hospital with cellulitis of the right foot secondary to an insect bite. Which intervention should the nurse implement first?

• A. Administer intravenous antibiotics
• B. Apply warm moist packs every two hours
• C. Elevate the right foot on two pillows
• D. Teach the client about skin and foot care

Correct answer: A

Rationale: Administering intravenous antibiotics is the priority intervention in this situation. Cellulitis is a bacterial infection that can spread rapidly, especially in individuals with diabetes. Immediate antibiotic therapy is crucial to prevent the infection from worsening and causing serious complications. Applying warm moist packs, elevating the foot, and teaching the client about skin and foot care are important interventions but should come after initiating antibiotic treatment to address the underlying infection.

5. What causes hepatic encephalopathy?

• A. Buildup of ammonia in the body
• B. Buildup of urea in the body
• C. Fatty infiltration of the liver
• D. Jaundice

Correct answer: A

Rationale: Hepatic encephalopathy is caused by the buildup of ammonia in the body, not urea. Ammonia accumulates due to liver dysfunction, leading to neurological symptoms. Fatty infiltration of the liver may lead to conditions like non-alcoholic fatty liver disease, but it is not the direct cause of hepatic encephalopathy. Jaundice is a symptom of liver dysfunction but is not the primary cause of hepatic encephalopathy.

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