Nursing Elites

1. During an assessment on a client in congestive heart failure, what is most likely to be revealed upon auscultation of the heart?

• A. S3 ventricular gallop
• B. Apical click
• C. Systolic murmur
• D. Split S2

Correct answer: A

Rationale: The correct answer is A: S3 ventricular gallop. An S3 sound is a common finding in congestive heart failure due to fluid overload in the heart. It is associated with decreased ventricular compliance. Choices B, C, and D are incorrect. An apical click is not typically associated with congestive heart failure. A systolic murmur may be heard in conditions like mitral regurgitation but is not specific to congestive heart failure. A split S2 is associated with conditions like pulmonary hypertension, not congestive heart failure.

2. A nurse is collecting data from a client who has diabetes and is overweight. The client tells the nurse that she wants to start an exercise program. Which of the following actions should the nurse take first?

• A. Determine the client's usual pattern of activity.
• B. Assist the client in developing a healthy eating plan.
• C. Encourage the client to join a support group.
• D. Provide the client with a list of signs and symptoms to report to the provider.

Correct answer: A

Rationale: Assessing the client's usual pattern of activity is crucial as it helps the nurse understand the client's current level of physical activity, any limitations, and areas needing improvement. This information is essential to create a safe and effective exercise plan tailored to the client's specific needs. Choice B, assisting the client in developing a healthy eating plan, is important but not the first step when the client's immediate goal is to start an exercise program. Encouraging the client to join a support group may be beneficial for motivation and emotional support but is not the priority at this stage. Providing a list of signs and symptoms to report to the provider is important for client education but is not the initial step when the client expresses a desire to begin an exercise program.

3. The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?

• A. Assess nail beds for color and refill
• B. Assess for postoperative arrhythmias
• C. Auscultate for pulmonary congestion
• D. Monitor equality of peripheral pulses

Correct answer: B

Rationale: Postoperative arrhythmias are a common and potentially serious complication after cardiac surgery, making them a priority to monitor. Assessing for postoperative arrhythmias takes precedence over other assessments like checking nail beds for color and refill, auscultating for pulmonary congestion, or monitoring peripheral pulses as arrhythmias can have immediate and severe implications for the child's health.

4. After a client has an enteral feeding tube inserted, the most accurate method for verification of placement is

• A. Abdominal x-ray
• B. Auscultation
• C. Flushing tube with saline
• D. Aspiration for gastric contents

Correct answer: D

Rationale: After the insertion of an enteral feeding tube, the most accurate method for verifying its placement is by aspirating gastric contents. This method ensures that the tube is correctly positioned in the stomach. Abdominal x-ray can provide additional confirmation but is not as immediate or practical. Auscultation and flushing the tube with saline are not as reliable as aspirating gastric contents for verifying proper placement of an enteral feeding tube.

5. A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action?

• A. Clamp the chest tube
• B. Call the surgeon immediately
• C. Prepare for blood transfusion
• D. Continue to monitor the rate of drainage

Correct answer: D

Rationale: In this scenario, the most appropriate nursing action is to continue to monitor the rate of drainage. Clamping the chest tube is not recommended as it can lead to a tension pneumothorax. Calling the surgeon immediately may not be necessary at this point unless the drainage rate significantly increases or other concerning symptoms develop. Preparing for a blood transfusion is premature without further assessment and monitoring of the client's condition. Monitoring the rate of drainage allows the nurse to assess for any potential complications and ensure that the drainage amount is within expected limits.

Similar Questions