Nursing Elites

1. During an assessment on a client in congestive heart failure, what is most likely to be revealed upon auscultation of the heart?

• A. S3 ventricular gallop
• B. Apical click
• C. Systolic murmur
• D. Split S2

Correct answer: A

Rationale: The correct answer is A: S3 ventricular gallop. An S3 sound is a common finding in congestive heart failure due to fluid overload in the heart. It is associated with decreased ventricular compliance. Choices B, C, and D are incorrect. An apical click is not typically associated with congestive heart failure. A systolic murmur may be heard in conditions like mitral regurgitation but is not specific to congestive heart failure. A split S2 is associated with conditions like pulmonary hypertension, not congestive heart failure.

2. The nurse receives an order to give a client iron by deep injection. The nurse knows that the reason for this route is to

• A. enhance absorption of the medication
• B. ensure that the entire dose of medication is given
• C. provide more even distribution of the drug
• D. prevent the drug from tissue irritation

Correct answer: D

Rationale: The correct answer is D. Deep injection helps to prevent tissue irritation caused by iron, which can be damaging to tissues. Option A is incorrect because deep injection does not primarily aim to enhance absorption, but rather to prevent tissue irritation. Option B is incorrect as the route of administration does not determine whether the entire dose is given. Option C is incorrect because the even distribution of the drug is not the main purpose of deep injection in this context.

3. A child is admitted to the pediatric unit with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse do first?

• A. Institute seizure precautions
• B. Monitor neurologic status every hour
• C. Place in respiratory/secretion precautions
• D. Cefotaxime IV 50 mg/kg/day divided q6h

Correct answer: C

Rationale: The correct answer is to place the child in respiratory/secretion precautions first. Meningococcal meningitis is highly contagious, and respiratory precautions are essential to prevent the spread of the infection. Seizure precautions may be necessary but are not the priority upon admission. Monitoring neurologic status is important but not the initial action needed. While antibiotic therapy like Cefotaxime is crucial, implementing isolation precautions to prevent transmission takes precedence in this situation.

4. A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to

• A. have the client identify coping methods
• B. get the description of the location and intensity of the pain
• C. accept the client's report of pain
• D. determine the client's status of pain

Correct answer: B

Rationale: The correct answer is B: 'get the description of the location and intensity of the pain.' When a client complains of pain, the initial step in pain assessment is to gather information about the location and intensity of the pain. This helps the nurse understand the nature of the pain and lays the groundwork for further assessment and management. Choice A is incorrect because identifying coping methods comes later in the assessment process. Choice C is incorrect as accepting the client's report of pain is important, but not the first step. Choice D is incorrect as determining the client's pain status also comes after gathering information about the pain.

5. A client wants to increase her daily intake of omega-3 fatty acids. Which of the following foods should the nurse suggest the client increase?

• A. Blueberries
• B. Soybean oil
• C. Citrus fruits
• D. Green tea

Correct answer: B

Rationale: The correct answer is B: Soybean oil. Soybean oil is a good source of omega-3 fatty acids, which are beneficial for heart health. Blueberries (choice A), citrus fruits (choice C), and green tea (choice D) are not significant sources of omega-3 fatty acids. Blueberries are rich in antioxidants, citrus fruits provide vitamin C, and green tea contains polyphenols, but they do not offer a substantial amount of omega-3 fatty acids compared to soybean oil.

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