Nursing Elites

1. After placing a stethoscope to auscultate S1 and S2 heart sounds, what should the nurse do to check for an S3 heart sound?

• A. Switch to the diaphragm of the stethoscope to hear any abnormal sounds
• B. Listen with the bell of the stethoscope at the same location
• C. Listen at a different location over the aortic area
• D. Switch to the apical area and reassess for S3 sounds

Correct answer: B

Rationale: To assess for an S3 heart sound, the nurse should listen with the bell of the stethoscope. An S3 heart sound is often low-pitched and best heard with the bell. Choice A is incorrect because switching to the diaphragm is not ideal for detecting low-pitched sounds like an S3. Choice C is incorrect as the S3 heart sound is best heard over the apex of the heart, not the aortic area. Choice D is incorrect because moving to the apical area is appropriate, but the nurse should specifically use the bell of the stethoscope to listen for S3 sounds.

2. A client with Type 2 diabetes is admitted with frequent hyperglycemic episodes and glycosylated hemoglobin (A1C) of 10%. What actions should the nurse include in the client's plan of care?

• A. Mixing glargine with aspart insulin to manage glucose levels.
• B. Teaching foot care to prevent injuries.
• C. Coordinating carbohydrate-controlled meals and subcutaneous injections.
• D. Reviewing site rotation for insulin injections.

Correct answer: C

Rationale: In managing a client with Type 2 diabetes experiencing frequent hyperglycemic episodes and with a high A1C level, it is crucial to coordinate carbohydrate-controlled meals and subcutaneous injections. This approach helps regulate blood glucose levels effectively. Mixing glargine with aspart insulin (Choice A) is not a recommended practice as these insulins have different onset and peak times. Teaching foot care (Choice B) is important in diabetes management but is not the priority in this scenario. Reviewing site rotation for insulin injections (Choice D) is important to prevent lipodystrophy but is not the immediate action needed to address the client's hyperglycemia and high A1C level.

3. A client is receiving treatment for glaucoma. Which class of medications is commonly used to decrease intraocular pressure?

• A. Anticholinergics
• B. Beta blockers
• C. Alpha blockers
• D. Diuretics

Correct answer: D

Rationale: Diuretics are commonly used to decrease intraocular pressure in clients with glaucoma. They work by reducing the production of aqueous humor in the eye or by increasing its outflow. Anticholinergics (Choice A) are not typically used in the treatment of glaucoma and can even increase intraocular pressure. Beta blockers (Choice B) are also commonly used in glaucoma treatment as they reduce aqueous humor production. Alpha blockers (Choice C) are not the first-line treatment for glaucoma and are not as commonly used as diuretics or beta blockers.

4. A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106, and he admits that he has not been taking the prescribed medication because the drugs make him feel bad. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?

• A. Stroke secondary to hemorrhage
• B. Myocardial infarction
• C. Heart failure
• D. Renal failure

Correct answer: A

Rationale: Stroke is a major complication of uncontrolled hypertension. Elevated BP, especially at levels like 158/106, can cause damage to blood vessels in the brain, leading to a hemorrhagic stroke. Controlling BP is essential to prevent such life-threatening events. Myocardial infarction (choice B) is more commonly associated with coronary artery disease, while heart failure (choice C) and renal failure (choice D) can be complications of uncontrolled hypertension but are not directly related to the elevated BP leading to a hemorrhagic stroke.

5. In assessing an adult client with a partial rebreather mask, the nurse notes that the oxygen reservoir bag does not deflate completely during inspiration and the client’s respiratory rate is 14 breaths/minute. What action should the nurse implement?

• A. Remove the mask immediately
• B. Document the assessment data
• C. Increase the oxygen flow
• D. Increase the respiratory rate setting

Correct answer: B

Rationale: The correct answer is to document the assessment data. In a partial rebreather mask, it is normal for the oxygen reservoir bag not to deflate completely during inspiration. Additionally, a respiratory rate of 14 breaths/minute falls within the normal range. Therefore, these findings indicate that the mask is functioning as intended. Removing the mask immediately is unnecessary as there are no signs of distress. Increasing the oxygen flow or adjusting the respiratory rate setting is not warranted based on the assessment findings, as they are within normal parameters.

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