Nursing Elites

1. Which instrument is used for auscultation?

• A. Percussion hammer
• B. Audiometer
• C. Stethoscope
• D. Sphygmomanometer

Correct answer: C

Rationale: Auscultation involves listening to internal sounds in the body, such as heart and lung sounds. The instrument used for auscultation is a stethoscope, which allows healthcare providers to listen to these sounds. The percussion hammer is used to elicit sounds on the body, the audiometer is used to measure hearing ability, and the sphygmomanometer is used to measure blood pressure. Therefore, the correct answer is 'Stethoscope.'

2. A client has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse?

• A. ''I am allergic to morphine.''
• B. ''I take antacids several times a day.''
• C. ''I had a blood clot in my leg several years ago.''
• D. ''It hurts to take a deep breath.''

Correct answer: B

Rationale: The correct answer is the statement 'I take antacids several times a day.' Antacids can alter the absorption of heparin, potentially affecting its effectiveness and increasing the risk of clot formation. This is a significant concern as it can impact the therapeutic outcome of heparin therapy. The other statements are not directly related to potential complications or interactions with heparin therapy.

3. A client with depression reports taking St. John's wort along with citalopram. The nurse should monitor the client for which of the following conditions as a result of an interaction between these substances?

• A. Serotonin syndrome
• B. Tardive dyskinesia
• C. Pseudoparkinsonism
• D. Acute dystonia

Correct answer: A

Rationale: When St. John's wort, an herbal supplement, is taken with citalopram, a selective serotonin reuptake inhibitor (SSRI), there is a risk of serotonin syndrome. Serotonin syndrome is a serious condition that can occur when there is an excess of serotonin in the body, leading to symptoms such as confusion, hallucinations, rapid heart rate, increased body temperature, and more. Monitoring for serotonin syndrome is crucial when these substances are taken together to prevent any potential harm to the client.

4. Palpating the midclavicular line is the correct technique for assessing

• A. Baseline vital signs
• B. Systolic blood pressure
• C. Respiratory rate
• D. Apical pulse

Correct answer: D

Rationale: Palpating the midclavicular line is the correct technique for assessing the apical pulse. The apical pulse is located at the point of maximal impulse (PMI), which is typically at the fifth intercostal space at the midclavicular line. This technique allows healthcare providers to accurately assess the heart rate and rhythm by listening to the heart sounds directly at this point.

5. The healthcare professional is preparing to take vital signs in an alert client admitted to the hospital with dehydration secondary to vomiting and diarrhea. What is the best method used to assess the client’s temperature?

• A. Oral
• B. Axillary
• C. Radial
• D. Heat-sensitive tape

Correct answer: A

Rationale: The most accurate method for assessing temperature in an alert client is the oral method. It provides a more reliable reflection of the body's core temperature compared to axillary or radial methods. In cases of dehydration, it is important to get an accurate temperature reading to monitor the client's condition closely. Axillary temperature may be affected by environmental factors, while radial temperature measurement is not a standard method for assessing core body temperature. Heat-sensitive tape is not a recognized method for assessing body temperature in clinical practice.

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