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 endocrine disorder would the nurse assess for in a client who has a closed head injury with increased intracranial pressure?

• A. Pheochromocytoma
• B. Diabetes insipidus
• C. Hashimoto’s disease
• D. Gynecomastia

Correct answer: B

Rationale: The correct answer is B, Diabetes insipidus. Diabetes insipidus can develop after a head injury due to damage to the hypothalamus or pituitary gland, leading to a deficiency in antidiuretic hormone (ADH). Pheochromocytoma (choice A) is a tumor of the adrenal gland and is not directly related to closed head injury or increased intracranial pressure. Hashimoto’s disease (choice C) is an autoimmune disorder affecting the thyroid gland, not commonly associated with head injuries. Gynecomastia (choice D) is the development of breast tissue in males and is not an endocrine disorder typically linked to closed head injuries.

3. A client who is postpartum and has been diagnosed with iron deficiency anemia is receiving education from a nurse. Which dietary recommendation should be included in the education plan?

• A. Yogurt and mozzarella
• B. Spinach and beef
• C. Fish and cottage cheese
• D. Turkey slices and milk

Correct answer: B

Rationale: The correct answer is B: 'Spinach and beef.' Spinach and beef are high in iron, which is crucial for treating iron deficiency anemia. Spinach is a good source of non-heme iron, while beef provides heme iron, making them effective choices to increase iron levels in the body. Yogurt and mozzarella (Choice A), fish and cottage cheese (Choice C), and turkey slices and milk (Choice D) do not contain as high iron content as spinach and beef, making them less effective in addressing iron deficiency anemia.

4. The nurse is caring for the client one (1) day postoperative sigmoid colostomy operation. Which independent nursing intervention should the nurse implement?

• A. Change the infusion rate of the intravenous fluid
• B. Encourage the client to discuss his or her feelings
• C. Administer opioid narcotic medications for pain management
• D. Assist the client out of bed to sit in the chair twice daily

Correct answer: D

Rationale: Assisting the client to sit in a chair is a crucial nursing intervention postoperatively. It helps prevent complications such as thrombosis, pneumonia, and pressure ulcers by promoting circulation and aiding in recovery. Changing the infusion rate of the intravenous fluid would require a physician's order and is not within the nurse's independent scope of practice. Encouraging the client to discuss feelings and administering medications for pain management are important interventions but may not be as immediately necessary as assisting the client in mobilizing early postoperatively.

5. The nurse supervises care of a client in Buck’s traction. The nurse determines that care is appropriate if which of the following is observed? (Select all that apply)

• A. The nurse removes the foam boot three times per day to inspect the skin
• B. The staff turn the client to the unaffected side
• C. The staff turn the client to the unaffected side and the nurse asks the client to dorsiflex the foot on the affected leg
• D. The nurse asks the client to dorsiflex the foot on the affected leg

Correct answer: C

Rationale: Correct care for a client in Buck’s traction includes turning the client to the unaffected side to prevent complications such as pressure ulcers. Additionally, asking the client to dorsiflex the foot on the affected leg helps prevent foot drop. Removing the foam boot three times per day to inspect the skin is unnecessary and could disrupt the traction, so it is not appropriate. Therefore, choices A and D are incorrect.

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