Nursing Elites

1. After placing a stethoscope to auscultate S1 and S2 heart sounds, what should the nurse do to check for an S3 heart sound?

• A. Switch to the diaphragm of the stethoscope to hear any abnormal sounds
• B. Listen with the bell of the stethoscope at the same location
• C. Listen at a different location over the aortic area
• D. Switch to the apical area and reassess for S3 sounds

Correct answer: B

Rationale: To assess for an S3 heart sound, the nurse should listen with the bell of the stethoscope. An S3 heart sound is often low-pitched and best heard with the bell. Choice A is incorrect because switching to the diaphragm is not ideal for detecting low-pitched sounds like an S3. Choice C is incorrect as the S3 heart sound is best heard over the apex of the heart, not the aortic area. Choice D is incorrect because moving to the apical area is appropriate, but the nurse should specifically use the bell of the stethoscope to listen for S3 sounds.

2. A client with cirrhosis is receiving lactulose. What is the most important assessment for the nurse to monitor?

• A. Monitor the client's ammonia levels.
• B. Monitor the client's blood glucose level.
• C. Monitor the client's potassium levels.
• D. Monitor the client's level of consciousness.

Correct answer: D

Rationale: The correct answer is to monitor the client's level of consciousness. Lactulose is used to reduce ammonia levels in hepatic encephalopathy. Monitoring the level of consciousness helps assess the effectiveness of lactulose therapy in improving the client's condition. Monitoring ammonia levels (choice A) is important, but assessing the client's response to therapy through their level of consciousness is more crucial. Blood glucose levels (choice B) and potassium levels (choice C) are not directly related to lactulose therapy for cirrhosis and hepatic encephalopathy.

3. A client presents with a suspected infection and has a fever of 102°F. What is the nurse's immediate priority?

• A. Administer antipyretics as ordered
• B. Take a blood culture before administering antibiotics
• C. Encourage fluid intake to prevent dehydration
• D. Monitor vital signs every hour

Correct answer: B

Rationale: The immediate priority for a client with a suspected infection and fever is to take a blood culture before administering antibiotics. This step is crucial to identify the causative organism and ensure appropriate treatment. Administering antipyretics or encouraging fluid intake are important but should come after obtaining the blood culture to avoid interfering with test results. Monitoring vital signs, although essential, is not the immediate priority compared to identifying the infectious agent.

4. A client with severe dehydration is admitted to the hospital. Which assessment finding indicates that the client's condition is improving?

• A. The client reports feeling less thirsty
• B. Urine output increases to 40 mL/hour
• C. Heart rate decreases from 120 to 110 beats per minute
• D. Skin turgor returns to normal

Correct answer: B

Rationale: An increase in urine output is a reliable indicator that the client's hydration status is improving. This reflects adequate fluid replacement and improved kidney function. Choice A is subjective and may not always indicate improved hydration. Choice C, while a positive sign, may be influenced by other factors such as medications or pain. Choice D, skin turgor returning to normal, is a delayed indicator of hydration status and may take time to improve even after hydration is initiated.

5. The nurse is developing a teaching plan for a client receiving chemotherapy. Which of the following should be the nurse's first priority?

• A. The client will maintain adequate nutrition.
• B. The client will manage side effects of treatment.
• C. The client will recognize signs and symptoms of infection.
• D. The client will experience a reduction in pain.

Correct answer: C

Rationale: The correct answer is C. Recognizing signs and symptoms of infection should be the nurse's first priority when developing a teaching plan for a client receiving chemotherapy. Chemotherapy often compromises the immune system, making patients more susceptible to infections. Early identification and prompt treatment of infections are crucial to prevent complications. Options A, B, and D are important aspects of care but recognizing signs of infection takes precedence due to the potential life-threatening consequences in clients undergoing chemotherapy treatment.

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