Nursing Elites

1. A healthcare provider is caring for a client who has a heart murmur. The healthcare provider is preparing to auscultate the pulmonary valve. Over which of the following locations should the healthcare provider place the bell of the stethoscope?

• A. Second intercostal space at the left sternal border
• B. Fifth intercostal space at the midclavicular line
• C. Fourth intercostal space at the left sternal border
• D. Fifth intercostal space at the left anterior axillary line

Correct answer: A

Rationale: The correct location to auscultate the pulmonary valve is the second intercostal space at the left sternal border. This area is where the pulmonary valve can best be heard due to its anatomical position. Choice B, the fifth intercostal space at the midclavicular line, is the location for auscultating the mitral valve. Choice C, the fourth intercostal space at the left sternal border, is the area for the tricuspid valve. Choice D, the fifth intercostal space at the left anterior axillary line, is the site for listening to the mitral valve as well. Therefore, option A is the correct choice for auscultating the pulmonary valve.

2. A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching she received about pain management?

• A. ''I think I should take my pain medication more often since it is not controlling my pain.''
• B. ''Breathing faster will help me keep my mind off of the pain.''
• C. ''It might help me to listen to music while I'm lying in bed.''
• D. ''I don't want to walk today because I have some pain.''

Correct answer: C

Rationale: The correct answer is C because listening to music is an effective nonpharmacological intervention for managing mild pain. Choice A is incorrect as increasing the frequency of pain medication without consulting healthcare providers can lead to adverse effects. Choice B is incorrect as distracting techniques like breathing faster may not address the pain effectively. Choice D is incorrect as avoidance of physical activity due to pain can hinder postoperative recovery.

3. A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first?

• A. Perform hand hygiene
• B. Identify the client using two identifiers
• C. Prepare the sterile field
• D. Don sterile gloves

Correct answer: A

Rationale: Performing hand hygiene is essential before any direct patient care procedure to prevent the spread of infection. Proper hand hygiene helps reduce the risk of introducing harmful microorganisms to the client, especially when dealing with a procedure like tracheostomy care. Identifying the client, preparing the sterile field, and donning sterile gloves are all important steps in tracheostomy care, but hand hygiene precedes them to maintain asepsis and ensure patient safety.

4. What is the most important aspect for the nurse to include in the discharge plan for a client performing his own dressing changes at home following abdominal surgery?

• A. Demonstration of appropriate hand hygiene
• B. Explanation of wound care technique
• C. Review of signs and symptoms of infection
• D. Instructions for when to contact the healthcare provider

Correct answer: A

Rationale: The most critical aspect for the nurse to include in the discharge plan for a client performing his own dressing changes at home following abdominal surgery is the demonstration of appropriate hand hygiene. Proper hand hygiene is essential to prevent the introduction of infection during dressing changes. While wound care technique, signs and symptoms of infection, and instructions for contacting the healthcare provider are all important components of the discharge plan, ensuring the client understands and practices proper hand hygiene is paramount to minimize the risk of infection. This choice takes precedence as it directly addresses infection prevention during the dressing changes, which is crucial for successful post-operative recovery.

5. A nurse is preparing to administer ketorolac 0.5 mg/kg IV bolus every 6 hr to a school-age child who weighs 66 lb. The available ketorolac injection is 30 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

• A. 0.5 mL
• B. 1 mL
• C. 1.5 mL
• D. 2 mL

Correct answer: A

Rationale: To calculate the dose, first convert the weight from pounds to kilograms. The child weighs 66 lb, which is approximately 30 kg. The prescribed dose is 0.5 mg/kg, so for a 30 kg child, the dose would be 0.5 mg/kg x 30 kg = 15 mg. Since the available ketorolac injection is 30 mg/mL, the nurse should administer 15 mg ÷ 30 mg/mL = 0.5 mL per dose. Therefore, choice A (0.5 mL) is the correct answer. Choices B, C, and D are incorrect as they do not accurately calculate the correct dose based on the child's weight and the concentration of the ketorolac injection.

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