Nursing Elites

1. A healthcare provider is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the provider hears the following sound. What action by the provider is most appropriate?

• A. Assess the client's lung sounds.
• B. Call the Rapid Response Team.
• C. Have the client sit upright.
• D. Listen to the client's lung sounds.

Correct answer: A

Rationale: The sound described is an S3 heart sound, which can indicate heart failure. The next appropriate action for the provider is to listen to the client's lung sounds. Lung sounds can provide additional information about the client's condition, especially when abnormal heart sounds are present. Calling the Rapid Response Team is not warranted based solely on the heart sound assessment. Having the client sit upright is not directly related to addressing the abnormal heart sound.

2. How does the pain of a myocardial infarction (MI) differ from stable angina?

• A. Accompanied by shortness of breath
• B. Feelings of fear or anxiety
• C. Lasts less than 15 minutes
• D. No relief from taking nitroglycerin

Correct answer: C

Rationale: The pain of a myocardial infarction (MI) is often accompanied by shortness of breath and feelings of fear or anxiety. Unlike stable angina, the pain of an MI typically lasts longer than 15 minutes and is not relieved by nitroglycerin. Additionally, it can occur without a known cause, unlike stable angina which often has a trigger such as exertion.

3. During an assessment, an older adult client's son reports that the client has been sick with a respiratory illness for the past 6 days. Which of the following assessment findings is a manifestation of pneumonia in the older adult client?

• A. Bradycardia
• B. Night sweats
• C. Confusion
• D. Narrowed pulse pressure

Correct answer: C

Rationale: Confusion is a common manifestation of pneumonia in older adults. It can result from inadequate oxygenation to the brain due to respiratory compromise. Bradycardia, night sweats, and narrowed pulse pressure are not typically specific findings associated with pneumonia and should be further assessed or monitored, but confusion is a key indicator that warrants immediate attention.

4. A client with emphysema is being assessed by a nurse. Which clinical manifestation should the nurse expect?

• A. Decreased chest expansion
• B. Cyanosis
• C. Pursed-lip breathing
• D. Bradypnea

Correct answer: C

Rationale: Pursed-lip breathing is a common manifestation in clients with emphysema. It helps to increase the duration of exhalation and reduce air trapping, aiding in the management of the condition. Decreased chest expansion and bradypnea are not typically associated with emphysema. While cyanosis can occur in severe cases, pursed-lip breathing is a more specific and commonly observed sign of emphysema.

5. A client has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should be taken?

• A. Increase the wall suction.
• B. Strip the chest tube.
• C. Clamp the chest tube.
• D. Reposition the client.

Correct answer: D

Rationale: When a client with a chest tube connected to wall suction complains of chest burning, it may indicate that the tube is irritating or compressing nearby tissues. Repositioning the client can help relieve this irritation by ensuring the tube is not kinked or pulling on the tissues. Increasing suction, stripping the tube, or clamping it are not appropriate actions and could potentially worsen the situation or cause harm.

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