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 nurse delegates a position change to a nursing assistive personnel. The nurse instructs the assistive personnel (AP) to place the patient in the lateral position. Which finding by the nurse indicates a correct outcome?

• A. Patient is lying on side.
• B. Patient is lying on back.
• C. Patient is lying semiprone.
• D. Patient is lying on abdomen.

Correct answer: A

Rationale: The correct answer is A: 'Patient is lying on side.' In the side-lying (or lateral) position, the patient rests on the side with the major portion of body weight on the dependent hip and shoulder. Choice B, 'Patient is lying on back,' is incorrect as it describes a supine position. Choice C, 'Patient is lying semiprone,' is incorrect as it refers to a position where the patient is partially lying on the abdomen. Choice D, 'Patient is lying on abdomen,' is incorrect as it describes a prone position where the patient is lying face down.

3. What intervention should be implemented by the LPN to reduce the risk of aspiration in a client with a nasogastric tube receiving continuous enteral feedings?

• A. Elevate the head of the bed to 30-45 degrees.
• B. Check residual volumes every 4 hours.
• C. Verify tube placement every shift.
• D. Flush the tube with water every 4 hours.

Correct answer: A

Rationale: Elevating the head of the bed to 30-45 degrees is crucial in reducing the risk of aspiration because it helps keep the gastric contents lower than the esophagus, thereby promoting proper digestion and preventing reflux. This position also aids in reducing the likelihood of regurgitation and aspiration of gastric contents. Checking residual volumes every 4 hours is important for monitoring feeding tolerance but does not directly address the risk of aspiration. Verifying tube placement every shift is essential for ensuring the tube is correctly positioned within the gastrointestinal tract but does not directly reduce the risk of aspiration. Flushing the tube with water every 4 hours may help maintain tube patency and prevent clogging, but it does not specifically address the risk of aspiration associated with nasogastric tube feedings.

4. When is a depressed client at highest risk for attempting suicide?

• A. Immediately after admission, during one-to-one observation
• B. 7 to 14 days after initiation of antidepressant medication and psychotherapy
• C. Following an angry outburst with family
• D. When the client is removed from the security room

Correct answer: B

Rationale: Depressed clients are at the highest risk of attempting suicide 7 to 14 days after starting antidepressant medication and psychotherapy. During this time, they may start to regain energy but still feel hopeless, which can increase the risk of suicidal ideation and behavior. Choices A, C, and D are incorrect because immediate post-admission, after an angry outburst with family, or when removed from a security room are not specific periods known to be associated with the highest risk of suicide in depressed clients.

5. While documenting in a client’s medical record, which of the following entries should the nurse record?

• A. “Incision without redness or drainage”
• B. “Drank adequate amounts of fluid with meals”
• C. “Administered pain medication”
• D. “Oral temperature slightly elevated at 0800”

Correct answer: D

Rationale: The correct answer is D because documenting specific observations, such as an oral temperature being slightly elevated at a specific time, is crucial for monitoring the client's health status accurately. This type of information helps in assessing trends and changes in the client's condition over time. Choice A is incorrect as it lacks specificity and does not provide measurable data about the client's condition. Choice B is incorrect because it is a general statement related to client behavior rather than a specific health observation. Choice C is incorrect as it reflects an action taken by the nurse and not a direct client's condition or observation.

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