Nursing Elites

1. While auscultating heart sounds, the nurse hears a swishing sound. How should this sound be documented?

• A. Heart murmur.
• B. Murmur.
• C. S3 sound.
• D. S4 sound.

Correct answer: B

Rationale: The correct answer is B: 'Murmur.' A murmur is a swishing sound heard during auscultation, typically caused by turbulent blood flow through the heart or valves. Choices C and D, 'S3 sound' and 'S4 sound,' refer to specific heart sounds associated with different cardiac conditions, not the general description of a swishing sound. Choice A, 'Heart murmur,' is redundant as 'murmur' alone is sufficient to describe the swishing sound heard.

2. A client with deep vein thrombosis (DVT) is prescribed heparin therapy. What laboratory value should the nurse monitor?

• A. Monitor the client’s liver function tests.
• B. Monitor the client’s prothrombin time (PT).
• C. Monitor the client’s partial thromboplastin time (PTT).
• D. Monitor the client’s red blood cell count.

Correct answer: C

Rationale: The correct answer is C: Monitor the client’s partial thromboplastin time (PTT). During heparin therapy for DVT, it is essential to monitor the PTT to assess the effectiveness of the medication in preventing clot formation. Monitoring the PTT helps ensure that the client is within the therapeutic range for anticoagulation. Choices A, B, and D are incorrect because liver function tests, prothrombin time (PT), and red blood cell count are not specifically monitored to assess the effectiveness of heparin therapy in preventing clot formation.

3. When a pediatric client is taking the beta-adrenergic blocking agent propranolol, what signs of overdose should the nurse instruct the parents to report?

• A. Seizures
• B. Increased respiratory rate
• C. Bradycardia
• D. Irritability

Correct answer: C

Rationale: When a pediatric client is taking propranolol, the nurse should instruct the parents to report signs of overdose, including bradycardia. Propranolol is a beta-blocker that can lead to dangerously slow heart rate as a sign of overdose. While increased respiratory rate, seizures, and irritability may occur in some cases, bradycardia is the most critical symptom indicating an overdose of this medication.

4. When assessing a recently delivered multigravida client, the nurse finds that her vaginal bleeding is more than expected. Which factor in this client's history is related to this finding?

• A. The client delivered a large baby
• B. She is a gravida 6, para 5
• C. The client had a cesarean delivery
• D. The client had a prolonged labor

Correct answer: B

Rationale: A client with a higher gravida and para count is at greater risk for uterine atony, which can lead to postpartum hemorrhage. The uterus may be less effective at contracting after multiple pregnancies, causing increased vaginal bleeding. Choices A, C, and D are incorrect because delivering a large baby, having a cesarean delivery, or experiencing prolonged labor do not directly correlate with an increased risk of postpartum hemorrhage in a multigravida client as compared to the gravida and para count.

5. A client receiving chemotherapy for cancer treatment is experiencing nausea and vomiting. What is the nurse's best intervention to manage these symptoms?

• A. Offer frequent, small meals
• B. Administer antiemetics before meals
• C. Encourage the client to eat a high-fat diet
• D. Provide the client with cold, carbonated beverages

Correct answer: B

Rationale: Administering antiemetics before meals is the best intervention to manage nausea and vomiting in clients receiving chemotherapy. This proactive approach helps control symptoms by preventing nausea from occurring, rather than waiting to treat it once symptoms have already started. Offering frequent, small meals (choice A) may worsen symptoms in some cases due to increased stomach activity. Encouraging a high-fat diet (choice C) can be difficult for nauseated clients and may not alleviate symptoms. Providing cold, carbonated beverages (choice D) could exacerbate nausea further due to the temperature and carbonation.

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