Nursing Elites

1. A client on a telemetry unit is being cared for by a nurse after a myocardial infarction. The client expresses, 'All this equipment is making me nervous.' Which of the following responses should the nurse make?

• A. 'All of this equipment can be frightening.'
• B. 'The equipment is necessary to monitor your condition.'
• C. 'You should try to ignore the equipment.'
• D. 'Try to relax; the equipment is not harmful.'

Correct answer: A

Rationale: Choice A is the most appropriate response as it acknowledges the client's feelings, showing empathy and understanding. It validates the client's experience, which can help reduce anxiety and build rapport. Choice B provides information but may not address the client's emotional needs. Choice C dismisses the client's concerns and does not offer support. Choice D minimizes the client's feelings and may not effectively address their anxiety.

2. A client diagnosed with a terminal illness asks the nurse about the nurse’s religious beliefs related to death and dying. An appropriate nursing response is to:

• A. Share personal beliefs
• B. Encourage the client to express their thoughts about death and dying
• C. Redirect the conversation to medical treatment
• D. Inform the client that the nurse’s beliefs are not relevant

Correct answer: B

Rationale: Encouraging the client to express their own thoughts about death and dying is an appropriate nursing response in this situation. It allows the client to explore and express their feelings, fears, and beliefs, facilitating a therapeutic conversation. Sharing personal beliefs (choice A) may not be appropriate as it could impose the nurse's beliefs on the client and hinder open discussion. Redirecting the conversation to medical treatment (choice C) may avoid addressing the client's emotional and spiritual needs. Informing the client that the nurse’s beliefs are not relevant (choice D) dismisses the client's concerns and does not encourage open communication.

3. 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.

4. A nurse delegates a position change to a nursing assistive personnel. The nurse instructs the assistive personnel (AP) to place the patient in the lateral position. Which finding by the nurse indicates a correct outcome?

• A. Patient is lying on side.
• B. Patient is lying on back.
• C. Patient is lying semiprone.
• D. Patient is lying on abdomen.

Correct answer: A

Rationale: The correct answer is A: 'Patient is lying on side.' In the side-lying (or lateral) position, the patient rests on the side with the major portion of body weight on the dependent hip and shoulder. Choice B, 'Patient is lying on back,' is incorrect as it describes a supine position. Choice C, 'Patient is lying semiprone,' is incorrect as it refers to a position where the patient is partially lying on the abdomen. Choice D, 'Patient is lying on abdomen,' is incorrect as it describes a prone position where the patient is lying face down.

5. A client is receiving continuous IV fluid therapy via a peripheral vein in the left forearm. Which of the following findings indicates that the client has developed phlebitis at the IV site?

• A. Erythema along the path of the vein
• B. Pitting edema at the insertion site
• C. Coolness of the client’s left forearm
• D. Pallor of the client’s left forearm

Correct answer: A

Rationale: Erythema (redness) along the path of the vein is a classic sign of phlebitis, indicating inflammation of the vein. This occurs due to irritation or infection at the IV site. Pitting edema (choice B) is not typically associated with phlebitis but suggests fluid overload or poor circulation. Coolness (choice C) and pallor (choice D) of the forearm are not characteristic signs of phlebitis but may indicate impaired circulation or reduced blood flow to the area.

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