Nursing Elites

1. When assessing a client’s heart sounds, the nurse hears a scratching sound during both systole and diastole. These sounds become more distinct when the nurse has the client sit up and lean forward. The nurse should document the presence of a:

• A. Pericardial friction rub
• B. Heart murmur
• C. S3 heart sound
• D. S4 heart sound

Correct answer: A

Rationale: A pericardial friction rub is characterized by a scratching sound that occurs during both systole and diastole. It becomes more distinct when the client is sitting up and leaning forward. This indicates an inflammation of the pericardial sac rubbing against the layers of the heart. Heart murmurs (choice B) are abnormal heart sounds caused by turbulent blood flow, not by friction like in a pericardial rub. S3 and S4 heart sounds (choices C and D) are additional heart sounds related to abnormal ventricular filling, not to pericardial friction rubs.

2. A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take?

• A. Check the catheter to see whether it is patent.
• B. Reassure the client that it is not possible for them to urinate.
• C. Re-catheterize the bladder with a larger-gauge catheter.
• D. Collect a urine specimen for analysis.

Correct answer: A

Rationale: When a client with an indwelling catheter reports a need to urinate, the nurse's initial action should be to check the catheter for patency. This is crucial to ensure that the catheter is not blocked, twisted, or kinked, which could lead to urinary retention. Reassuring the client without assessing the catheter could delay necessary interventions. Re-catheterizing the bladder with a larger-gauge catheter should not be the first step unless catheter patency is confirmed as an issue. Collecting a urine specimen for analysis is important but not the immediate priority when the client reports a need to urinate.

3. A healthcare professional is admitting a client who has decreased circulation in his left leg. Which of the following actions should the healthcare professional take first?

• A. Evaluate pedal pulses
• B. Assess skin temperature
• C. Check for capillary refill
• D. Measure the leg circumference

Correct answer: A

Rationale: Evaluating pedal pulses should be the first action taken as it provides immediate information about circulation. This assessment helps in determining the adequacy of blood flow in the client's leg. Assessing skin temperature, checking for capillary refill, and measuring leg circumference are important assessments; however, evaluating pedal pulses is the most crucial initial step in this scenario. Skin temperature assessment and capillary refill check can provide additional valuable information about perfusion, while measuring leg circumference is useful in monitoring for edema. Therefore, for a client with decreased circulation in the left leg, evaluating pedal pulses takes precedence over the other assessments.

4. A client is on bed rest following an abdominal surgery. Which of the following findings indicates the need to increase the frequency of position changes?

• A. Flat rash on the client's ankle
• B. Non-blanching red area over the client's trochanter
• C. Ecchymosis on the client's left shoulder
• D. Petechiae on the client's right anterior thigh

Correct answer: B

Rationale: The presence of a non-blanching red area over the client's trochanter is a concerning finding as it indicates possible pressure ulcer formation. This finding necessitates an increase in the frequency of position changes to prevent skin breakdown. Choices A, C, and D do not directly correlate with the need for increased position changes. A flat rash, ecchymosis, and petechiae may have different causes and would not be addressed by changing the client's position more frequently.

5. A healthcare professional is admitting a client who has tuberculosis. Which of the following types of transmission precautions should the healthcare professional plan to initiate?

• A. Contact
• B. Droplet
• C. Airborne
• D. Protective environment

Correct answer: C

Rationale: Tuberculosis is transmitted through airborne particles, so airborne precautions are necessary to prevent the spread of the disease. Airborne precautions (Choice C) involve measures such as negative pressure rooms and N95 respirators to prevent the transmission of infectious agents that remain infectious over long distances when suspended in the air. Contact precautions (Choice A) are used for diseases that spread through direct contact with the patient or their environment. Droplet precautions (Choice B) are for diseases transmitted through respiratory droplets, typically over short distances. Protective environment (Choice D) is used for clients who are immunocompromised to protect them from environmental pathogens, not for diseases like tuberculosis that spread through the air.

Similar Questions