Nursing Elites

1. 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.

2. A client has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter requires irrigation?

• A. Bladder scan shows 525 mL of urine
• B. Urine has a strong odor
• C. The client reports abdominal discomfort
• D. The catheter is blocked or not draining

Correct answer: D

Rationale: The correct answer is D because if the catheter is blocked or not draining, it may need irrigation to restore proper flow. Option A, 'Bladder scan shows 525 mL of urine,' does not necessarily indicate the need for irrigation as it could be within the expected range for catheter drainage. Option B, 'Urine has a strong odor,' may indicate a urinary tract infection but does not directly correlate with the need for catheter irrigation. Option C, 'The client reports abdominal discomfort,' could indicate various issues but does not specifically suggest the need for catheter irrigation.

3. A client with type 1 diabetes mellitus is experiencing hypoglycemia. What is the best initial action for the LPN/LVN to take?

• A. Administer glucagon intramuscularly.
• B. Give the client 4 ounces of orange juice.
• C. Give the client a snack containing protein and carbohydrates.
• D. Encourage the client to rest until symptoms resolve.

Correct answer: B

Rationale: The best initial action for a client with type 1 diabetes mellitus experiencing hypoglycemia is to give them 4 ounces of orange juice. Orange juice quickly raises blood glucose levels in a hypoglycemic client. Administering glucagon intramuscularly is not the best initial action for hypoglycemia; it is usually reserved for severe hypoglycemia cases. Giving a snack containing protein and carbohydrates is not as rapid as orange juice in raising blood glucose levels during hypoglycemia. Encouraging the client to rest until symptoms resolve does not address the immediate need to raise blood glucose levels in a hypoglycemic state.

4. A healthcare professional is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the healthcare professional use as a psychomotor approach to learning?

• A. Practice sessions
• B. Demonstrations
• C. Written instructions
• D. Group discussions

Correct answer: A

Rationale: Practice sessions are an effective psychomotor approach to learning for adolescents with ostomies as they involve hands-on practice of ostomy care skills, which can help reinforce learning through active engagement. Demonstrations (choice B) can be helpful in providing visual guidance but may not offer the same level of active participation and practice as practice sessions. Written instructions (choice C) may be useful for reference but may not be as effective in developing psychomotor skills. Group discussions (choice D) focus more on verbal exchange and may not directly address the need for hands-on skill development required in managing ostomies. Therefore, practice sessions are the most suitable method for enhancing psychomotor learning in this scenario.

5. When parents call the emergency room to report that a toddler has swallowed drain cleaner, the nurse instructs them to call for emergency transport to the hospital. While waiting for an ambulance, what substance should the nurse suggest the parents give the child sips of?

• A. Tea
• B. Water
• C. Milk
• D. Soda

Correct answer: B

Rationale: The correct answer is B: Water. Giving sips of water can help dilute the drain cleaner while waiting for emergency transport, which may help reduce the potential harm caused by the ingestion. Choices A, C, and D are incorrect because tea, milk, and soda can interact with the chemicals in the drain cleaner or increase the risk of vomiting, which is not recommended in this situation.

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