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. Performing and supervising therapeutic and preventive procedures that have been planned for a patient is part of which of the following steps for determining and fulfilling the nursing care needs of the patient?

• A. Evaluation
• B. Planning
• C. Implementation
• D. Assessment

Correct answer: C

Rationale: The correct answer is C: Implementation. In nursing care, implementation involves carrying out and supervising the planned procedures for the patient. This step focuses on putting the care plan into action. Choice A, Evaluation, involves assessing the effectiveness of the care provided, not performing procedures. Choice B, Planning, is about developing a plan of care, not executing it. Choice D, Assessment, is the initial step in the nursing process where data is collected and analyzed to determine the patient's needs, not the step involving performing and supervising procedures.

3. The nurse is caring for a client in a sickle cell crisis. Which is the pain regimen of choice to relieve the pain?

• A. Frequent aspirin (acetylsalicylic acid) and a non-narcotic analgesic
• B. Motrin (ibuprofen), an NSAID, PRN
• C. Demerol (meperidine), a narcotic analgesic, every four (4) hours
• D. Morphine, a narcotic analgesic, every two (2) to three (3) hours PRN

Correct answer: D

Rationale: Morphine is the preferred analgesic in sickle cell crisis due to its potency and effectiveness in managing severe pain.

4. In a routine sputum analysis, which of the following indicates proper nursing action before sputum collection?

• A. Secure a clean container
• B. Discard the container if the outside becomes dirty
• C. Rinse the client's mouth with Listerine before collection
• D. Tell the client that 4 tablespoons of sputum are needed

Correct answer: A

Rationale: The correct answer is to secure a clean container before sputum collection. This is essential to prevent contamination of the specimen, ensuring accurate test results and avoiding the introduction of external particles or bacteria. Choice B is incorrect because discarding the container if the outside becomes dirty is not necessary; the cleanliness of the inside is crucial. Choice C is incorrect as rinsing the client's mouth with Listerine before collection may introduce unwanted substances that can affect the test results. Choice D is incorrect as the amount of sputum required can vary depending on the test, and specifying a specific amount without medical guidance is not appropriate.

5. The nurse is teaching basic cardiopulmonary resuscitation (CPR) to individuals in the community. What is the correct order of basic CPR steps?

• A. Ensure the scene is safe, assess responsiveness, call for help, begin chest compressions, give two rescue breaths
• B. Give two rescue breaths
• C. Look, listen, and feel for breathing
• D. Begin chest compressions

Correct answer: A

Rationale: The correct order of basic CPR steps is as follows: first, ensure the scene is safe to approach, then assess the individual's responsiveness. After confirming the need for help, start chest compressions, then provide two rescue breaths. Option B, 'Give two rescue breaths,' is incorrect as chest compressions should be initiated before giving rescue breaths. Option C, 'Look, listen, and feel for breathing,' is also incorrect as immediate chest compressions are crucial in CPR. Option D, 'Begin chest compressions,' is partially correct but misses the crucial initial steps of ensuring scene safety and assessing responsiveness.

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