Nursing Elites

1. Where should a nurse auscultate the apex beat?

• A. At the fifth intercostal space, along the midclavicular line
• B. At the mid-sternum
• C. 2 inches to the left of the lower end of the sternum
• D. 1 inch to the left of the xiphoid process

Correct answer: A

Rationale: The correct location to auscultate the apex beat is at the fifth intercostal space, along the midclavicular line. This is where the apical impulse, also known as the point of maximal impulse (PMI), can be best heard. Choices B, C, and D are incorrect anatomical locations for auscultating the apex beat, which makes them incorrect choices. Auscultating at the correct location allows healthcare providers to assess the heart's function and detect any abnormalities in heart sounds, which is crucial for comprehensive patient care.

2. Which substance would most likely need to be restricted in patients with heart failure who use diuretics to help reduce fluid retention?

• A. potassium
• B. magnesium
• C. sodium
• D. chloride

Correct answer: C

Rationale: Sodium restriction is crucial in heart failure management to prevent fluid retention, which can worsen symptoms of heart failure.

3. An adolescent client has bloodshot eyes, a voracious appetite, and dry mouth. Which drug abuse would the nurse most likely suspect?

• A. Marijuana
• B. Amphetamines
• C. Barbiturates
• D. Anxiolytics

Correct answer: A

Rationale: The symptoms described, including bloodshot eyes, a voracious appetite, and dry mouth, are consistent with marijuana use. Bloodshot eyes are a common side effect of marijuana due to its effect on blood vessels in the eyes. Marijuana also often causes an increase in appetite (known as 'the munchies') and can result in dry mouth. Amphetamines typically cause symptoms like increased alertness, energy, and decreased appetite. Barbiturates and anxiolytics would not typically cause bloodshot eyes, a voracious appetite, and dry mouth as described in the scenario. Therefore, the most likely drug abuse the nurse would suspect in this case is marijuana.

4. When surgery is on-going, who coordinates the activities outside, including the family?

• A. Orderly/clerk C. Circulating Nurse
• B. Nurse Supervisor D. Anesthesiologist
• C.
• D.

Correct answer: B

Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.

5. Substance abuse is different from substance dependence in that, substance dependence:

• A. includes characteristics of adverse consequences and repeated use
• B. requires long term treatment in a hospital based program
• C. produces less severe symptoms than that of abuse
• D. includes characteristics of tolerance and withdrawal

Correct answer: D

Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.

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