Nursing Elites

1. The nurse is told in report that the client has aortic stenosis. Which anatomical position should the nurse auscultate to assess the murmur?

• A. Second intercostal space, right sternal border
• B. Erb’s point
• C. Second intercostal space, left sternal border
• D. Fourth intercostal space, left sternal border

Correct answer: A

Rationale: The correct answer is A: Second intercostal space, right sternal border. The aortic valve is best auscultated at the second intercostal space, right sternal border, where the murmur of aortic stenosis is heard most clearly. Choices B, C, and D are incorrect as they are not the recommended anatomical positions for auscultating the murmur of aortic stenosis.

2. The nurse is caring for the client recovering from a percutaneous renal biopsy. Which data indicate that the client is complying with client teaching?

• A. The client lies flat in the supine position for 12 hours
• B. The client continues oral fluids restriction while on bed rest
• C. The client’s family changed the dressing on return to the room
• D. The family activates the patient-controlled analgesia pump

Correct answer: A

Rationale: The correct answer is A. Lying flat in the supine position for 12 hours after a renal biopsy is essential to prevent bleeding and promote recovery. This position helps apply pressure to the biopsy site, reducing the risk of bleeding. Choices B, C, and D are incorrect because continuing oral fluids restriction, changing the dressing, and activating the patient-controlled analgesia pump do not directly indicate compliance with the crucial post-biopsy teaching of maintaining the supine position.

3. Which of the following describes the four-step method of assessment, planning, implementation, and evaluation?

• A. It is a problem-focused process of continued nursing care
• B. It is an open-ended process of continued nursing care
• C. It is a circular process of continued nursing care
• D. It is a trial-and-error process of continued nursing care

Correct answer: C

Rationale: The correct answer is C: 'It is a circular process of continued nursing care.' The four-step method of assessment, planning, implementation, and evaluation is a continuous and cyclical process in nursing care. Choice A is incorrect because the method is not solely problem-focused but involves multiple steps. Choice B is incorrect as it does not capture the structured nature of the four-step method. Choice D is incorrect as it implies a random approach rather than a systematic and organized process.

4. The nurse is preparing the plan of care for a client with fluid volume deficit. Which interventions should the nurse include in the plan of care?

• A. Monitor vital signs every two (2) hours until stable
• B. Weigh the client in the same clothing at the same time daily
• C. Administer mouth care every eight (8) hours
• D. A, B, and C

Correct answer: D

Rationale: The correct interventions to include in the plan of care for a client with fluid volume deficit are monitoring vital signs every two hours until stable, weighing the client in the same clothing at the same time daily, and assessing skin turgor. These interventions are crucial for managing and detecting fluid volume changes. Administering mouth care every eight hours is not directly related to managing fluid volume deficit and does not address the key aspects of monitoring and assessing fluid status, making it an incorrect choice.

5. People at higher risk for drug-nutrient interactions include:

• A. Infants
• B. People with diabetes
• C. Women of childbearing age
• D. Older men and women

Correct answer: D

Rationale: Older men and women are at a higher risk for drug-nutrient interactions due to factors like polypharmacy, changes in metabolism, and physiological changes associated with aging. Infants are less likely to be exposed to a wide range of medications, reducing their risk. People with diabetes and women of childbearing age may have specific nutrient needs or considerations, but they are not typically at a higher risk for drug-nutrient interactions compared to older adults.

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