Nursing Elites

1. A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve?

• A. Second intercostal space to the right of the sternum
• B. Fifth intercostal space at the midclavicular line
• C. Left sternal border
• D. Fifth intercostal space at the anterior axillary line

Correct answer: B

Rationale: The correct placement to auscultate the aortic valve is at the second intercostal space to the right of the sternum, which coincides with the aortic area. The choice stating 'Fifth intercostal space at the midclavicular line' is the correct answer for auscultating the aortic valve. Placing the stethoscope at the left sternal border would be more suitable for listening to the tricuspid valve. The fifth intercostal space at the anterior axillary line is the recommended area for auscultating the mitral valve. Therefore, choice B is the correct answer for assessing the aortic valve in a client with a history of a heart murmur related to aortic valve stenosis.

2. During a Weber test, what is an appropriate action for the nurse to take?

• A. Deliver a series of high-pitched sounds at random intervals.
• B. Place an activated tuning fork in the middle of the client's forehead.
• C. Hold an activated tuning fork against the client's mastoid process.
• D. Whisper a series of words softly into one ear.

Correct answer: B

Rationale: During a Weber test, the nurse should place an activated tuning fork in the middle of the client's forehead. This test is used to assess for lateralization of sound in a client with possible hearing issues. Choice A is incorrect because the Weber test does not involve delivering high-pitched sounds at random intervals. Choice C is incorrect as it describes the Rinne test, not the Weber test. Choice D is incorrect as whispering words into one ear is not part of the Weber test procedure.

3. When using an open irrigation technique for a client's catheter, what action should the nurse take?

• A. Subtract the amount of irrigant used from the client's urine output.
• B. Add the amount of irrigant used to the urine output measurement.
• C. Measure the amount of irrigant used separately from the urine output.
• D. Document the total amount of fluid used for irrigation only.

Correct answer: A

Rationale: The correct action for the nurse to take when using an open irrigation technique for a client's catheter is to subtract the amount of irrigant used from the client's urine output. This subtraction helps accurately assess the client's output by accounting for the volume of irrigant introduced. Choice B is incorrect because adding the irrigant to the urine output measurement would falsely inflate the total output, leading to inaccurate assessment. Choice C is incorrect as measuring the amount of irrigant separately does not provide an accurate assessment of the client's total output as it disregards the irrigant's contribution. Choice D is incorrect as documenting the total fluid used for irrigation only does not differentiate between the irrigant and the client's actual urine output, which is crucial for accurate monitoring and assessment.

4. At a mobile screening clinic, a nurse is assessing a client who reports a history of a heart murmur due to aortic stenosis. To auscultate the aortic valve, where should the nurse place the stethoscope?

• A. Second intercostal space to the right of the sternum
• B. Fifth intercostal space to the left of the sternum
• C. Third intercostal space to the left of the sternum
• D. Fourth intercostal space at the midclavicular line

Correct answer: A

Rationale: The correct location to auscultate the aortic valve is the second intercostal space to the right of the sternum. This area corresponds to the aortic valve area where aortic valve sounds are best heard. Choices B, C, and D are incorrect for auscultating the aortic valve. The fifth intercostal space to the left of the sternum is where the mitral valve is best heard, the third intercostal space to the left of the sternum is where the pulmonic valve is best heard, and the fourth intercostal space at the midclavicular line is where the tricuspid valve is best auscultated.

5. A healthcare professional is caring for a child who has a prescription for a blood transfusion. The parents have refused the treatment due to religious beliefs. Which of the following actions should the healthcare professional take?

• A. Examine personal values about the issue.
• B. Respect the parents' decision and provide alternative treatment options.
• C. Seek a court order to proceed with the transfusion.
• D. Discuss the issue with the child.

Correct answer: A

Rationale: Examining personal values about the issue is crucial for the healthcare professional to provide unbiased care while still respecting the parents' beliefs. Choice B is incorrect because respecting the parents' decision is essential, but providing alternative treatment options may not be warranted in this situation where the parents' decision is based on religious beliefs. Seeking a court order (Choice C) should only be considered as a last resort when the child's life is in immediate danger and all other options have been exhausted. Discussing the issue with the child (Choice D) may not be appropriate as the child may not fully comprehend the situation or the implications of going against the parents' beliefs.

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