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. Which of the following describes a process of heat loss involving the transfer of heat from one surface to another?

• A. Radiation
• B. Conduction
• C. Convection
• D. Evaporation

Correct answer: B

Rationale: Conduction is the process of heat transfer that occurs between objects or substances that are in direct contact with each other. In this process, heat is transferred from a hotter surface to a cooler surface through direct contact. This type of heat transfer does not involve the movement of the substances themselves, only the transfer of thermal energy. Choice A, Radiation, is the transfer of heat in the form of electromagnetic waves and does not require a medium. Choice C, Convection, involves the transfer of heat through the movement of fluids (liquids or gases) due to density differences. Choice D, Evaporation, is a cooling process that involves the transformation of a liquid into a gas, absorbing heat in the process.

3. The nurse supervises care of a client who is receiving enteral feeding via a nasogastric tube. The nurse determines that care is appropriate if which of the following is observed? (Select all that apply)

• A. The nursing assistant aspirates and measures the amount of gastric aspirate
• B. The nursing assistant elevates the head of the client’s bed 30 degrees
• C. The nursing assistant warms the formula to room temperature
• D. B, C

Correct answer: D

Rationale: The correct answer is D because elevating the head of the bed reduces the risk of aspiration, and warming the formula to room temperature helps prevent discomfort and complications. Choice A is incorrect as only licensed healthcare professionals should aspirate and measure the amount of gastric aspirate. Choice B is correct as it helps prevent aspiration. Choice C is correct as warming the formula can prevent discomfort.

4. A client scheduled for surgery cannot sign the operative consent form because he has been sedated with opioid analgesics. The nurse should take which best action regarding the informed consent?

• A. Obtain a court order for the surgery
• B. Sign the informed consent on behalf of the client
• C. Send the client to surgery without the consent form being signed
• D. Obtain a telephone consent from a family member, with the consent being witnessed by two healthcare providers

Correct answer: D

Rationale: In situations where a client is unable to sign the consent form, obtaining a telephone consent from a family member, with the consent being witnessed by two healthcare providers, is the best course of action. This ensures that the client's best interests are considered and that proper authorization is obtained. Option A, obtaining a court order, is not necessary in this scenario and could delay the surgery. Option B, signing the consent on behalf of the client, is not appropriate as it may raise ethical and legal concerns. Option C, sending the client to surgery without a signed consent form, is not advisable as it violates the principles of informed consent and places the client at risk.

5. The nurse understands that which characteristics are of anthrax? Select all that apply.

• A. Cutaneous lesions become a black eschar and flu-like symptoms are a sign of pulmonary anthrax
• B. Cutaneous lesions become a black eschar
• C. Gastrointestinal anthrax causes blood anthrax
• D. Flu-like symptoms are a sign of pulmonary anthrax

Correct answer: A

Rationale: The correct characteristics of anthrax are that cutaneous anthrax causes black eschar lesions, and flu-like symptoms are typical of pulmonary anthrax. Choice B is incorrect because it only includes information about cutaneous anthrax lesions but doesn't cover the flu-like symptoms of pulmonary anthrax. Choice C is incorrect as gastrointestinal anthrax does not cause 'blood anthrax,' it causes symptoms like severe abdominal pain, vomiting, and diarrhea. Choice D is incorrect as flu-like symptoms are associated with pulmonary anthrax, not with gastrointestinal anthrax.

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