Nursing Elites

1. When assessing the carotid artery of a client with cardiovascular disease, what action should a nurse perform?

• A. Palpating the carotid artery in the upper third of the neck
• B. Palpating both arteries simultaneously to compare amplitude
• C. Listening to the carotid artery, using the bell of the stethoscope to assess for bruits
• D. Instructing the client to take slow, deep breaths while the nurse listens to the carotid artery

Correct answer: C

Rationale: When assessing the carotid artery of a client with cardiovascular disease, the nurse should listen to the carotid artery using the bell of the stethoscope to assess for bruits. This is crucial in detecting abnormal sounds that may indicate underlying pathology. Palpating the carotid artery in the upper third of the neck can trigger a vagal response, leading to a decrease in heart rate, which is undesirable. Palpating both arteries simultaneously can disrupt blood flow to the brain. Instructing the client to take slow, deep breaths is unnecessary and not a standard practice during carotid artery assessment.

2. The nurse is observing a client self-administer two crushable medications through their G-tube. Which of the following would indicate a need for further instruction?

• A. The client flushes the G-tube before administering the medications, in between the two medications, and after the medications.
• B. The client states they will remain in the Semi-Fowler's position for 30 minutes following the administration of the medications.
• C. The client mixes each medication separately in warm water.
• D. The client mixes their medications with their tube-feeding formula.

Correct answer: D

Rationale: The correct answer is that the client mixes their medications with their tube-feeding formula. Medications should not be mixed with tube-feeding formula or other medications as it may alter their effectiveness. The G-tube should be flushed before, between, and after the medications to prevent clogging and ensure proper administration. The client should remain in the Semi-Fowler's position for at least 30 minutes after medication administration to prevent reflux. Choice B is correct as it aligns with the proper post-administration positioning. Choices A and C are incorrect as flushing the G-tube before, between, and after medications, and mixing each medication separately in warm water are appropriate procedures that do not indicate a need for further instruction.

3. What is the most appropriate intervention for a client with suspected genitourinary trauma and visible blood at the urethral meatus?

• A. Insertion of a Foley catheter.
• B. In-and-out catheter specimen for urinalysis.
• C. A voided urine specimen for urinalysis.
• D. A urologist consult.

Correct answer: D

Rationale: A urologist consult is the most appropriate intervention for a client with visible blood at the urethral meatus and suspected genitourinary trauma. This specialist can evaluate the extent of the trauma and provide the necessary treatment. Foley catheter insertion (Choice A) and in-and-out catheter specimen for urinalysis (Choice B) are contraindicated in the presence of genitourinary trauma as they can worsen the injury. While a voided urine specimen for urinalysis (Choice C) may be ordered by the physician, it does not address the specific management needed for genitourinary trauma. Therefore, a urologist consult is the best option in this scenario.

4. A nurse assisting with data collection regarding the client's eyes notes that the pupils get larger when the client looks at an object in the distance and become smaller when the client looks at a nearby object. How does the nurse document this finding?

• A. Myopia
• B. Hyperopia
• C. Photophobia
• D. Accommodation

Correct answer: D

Rationale: The correct answer is Accommodation. Accommodation is the process by which the eye adjusts its focus to see objects at different distances. When the pupils get larger when the client looks at an object in the distance and become smaller when looking at a nearby object, it indicates the normal functioning of the eye's accommodation mechanism. Myopia refers to nearsightedness, where distant objects appear blurry. Hyperopia refers to farsightedness, where close objects appear blurry. Photophobia is an abnormal sensitivity to light. Therefore, the correct term to document the finding of the pupils adjusting based on the distance of the object is 'Accommodation.'

5. A nurse is determining the fetal heart rate (FHR) and places the fetoscope on the mother's abdomen to count the FHR. The nurse simultaneously palpates the mother's radial pulse and notes that it is synchronized with the sounds heard through the fetoscope. Which action should the nurse take?

• A. Count the FHR for 60 seconds, ensuring that it is synchronized consistently with the mother's radial pulse.
• B. Move the fetoscope to another area on the mother's abdomen to locate the fetal heart.
• C. Ask the mother to lie still while both the FHR and the radial pulse rate are counted.
• D. Count the FHR for 30 seconds and then count the radial pulse rate of the mother for 30 seconds.

Correct answer: B

Rationale: When auscultating the fetal heart rate, the nurse would place the fetoscope on the maternal abdomen, over the fetal back. The nurse would then palpate the mother's radial pulse. If her pulse is synchronized with the sounds from the fetoscope, the nurse would move the fetoscope to another area on the mother's abdomen to locate the FHR. The nurse needs to be sure that the FHR is what is actually being heard. Other sounds that may be heard are the funic sound (blood flowing through the umbilical cord) and the uterine sound (blood flowing through the uterine vessels). The funic sound is synchronized with the FHR; the uterine sound is synchronized with the mother's pulse. Therefore, moving the fetoscope to a different area will help in accurately locating and counting the fetal heart rate. Choice A is incorrect because counting for 60 seconds without changing the position may not address the issue of accurately locating the FHR. Choice C is incorrect as it does not address the need to reposition the fetoscope to locate the fetal heart. Choice D is incorrect because counting the FHR and the radial pulse rate separately may not help in differentiating the two sounds.

Similar Questions