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 is developing an individualized plan of care for a patient. Which action is important for the nurse to take?

• A. Establish goals that are measurable and realistic.
• B. Set goals that are a little beyond the capabilities of the patient.
• C. Use the nurse's own judgment and not be swayed by family desires.
• D. Explain that without taking alignment risks, there can be no progress.

Correct answer: A

Rationale: When developing an individualized plan of care for a patient, the nurse must set goals that are specific, measurable, achievable, realistic, and time-bound (SMART). Choice A is correct as it emphasizes the importance of establishing goals that are measurable and realistic, ensuring they are attainable within a specific timeframe. Setting goals that are beyond the capabilities of the patient (Choice B) can lead to frustration and lack of progress. Using only the nurse's judgment and disregarding family desires (Choice C) may not consider important aspects of the patient's social support and preferences. Explaining that progress requires taking alignment risks (Choice D) is not a standard approach in nursing care planning and may confuse the patient or hinder trust in the nurse's decision-making.

3. A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago but feels fine now. What action is best for the LPN/LVN to take?

• A. Record the coughing incident. No further action is required at this time.
• B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider.
• C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
• D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.

Correct answer: C

Rationale: After a client experiences severe coughing following nasogastric tube feedings, it is crucial to verify proper tube placement. Checking the pH of fluid withdrawn from the tube helps confirm the tube's correct positioning. Option A is incorrect because further action is necessary to ensure the client's safety. Option B is inappropriate as it suggests stopping the feeding without assessing the tube's placement. Option D is incorrect as injecting air into the tube may lead to further complications if the tube is not positioned correctly.

4. What is the most important action for the nurse to take to prevent infection in a client who has just returned from surgery with an indwelling urinary catheter in place?

• A. Change the catheter every 72 hours.
• B. Ensure the catheter tubing is free of kinks.
• C. Clean the perineal area with antiseptic solution daily.
• D. Irrigate the catheter with normal saline every shift.

Correct answer: B

Rationale: The most important action to prevent infection in a client with an indwelling urinary catheter is to ensure the catheter tubing is free of kinks. This action helps prevent obstruction, ensures proper drainage, and reduces the risk of infection. Changing the catheter every 72 hours is not necessary unless clinically indicated and may introduce unnecessary risk. Cleaning the perineal area with antiseptic solution daily is important for general hygiene but not the most critical action for catheter-related infection prevention. Irrigating the catheter with normal saline every shift is not a routine nursing intervention for catheter care and may increase the risk of introducing pathogens.

5. When a healthcare professional makes an initial assessment of a client who is post-op following gastric resection, the client's NG tube is not draining. The healthcare professional's attempt to irrigate the tube with 10ml of 0.9% NaCl was unsuccessful, so they determine that the tube was obstructed. Which of the following actions should the healthcare professional take?

• A. Notify the healthcare provider.
• B. Attempt to irrigate the tube with a larger volume of saline.
• C. Replace the NG tube with a new one.
• D. Reposition the client to see if that helps the tube drain.

Correct answer: A

Rationale: If an NG tube is obstructed and cannot be irrigated successfully, notifying the healthcare provider is the appropriate action to take for further management. This is crucial as the healthcare provider may need to assess the situation, provide guidance, or intervene with specific interventions. Attempting to irrigate the tube with a larger volume of saline (Choice B) may exacerbate the situation if the tube is truly obstructed. Replacing the NG tube with a new one (Choice C) should not be the initial action unless advised by the healthcare provider. Repositioning the client (Choice D) may not necessarily resolve the tube obstruction and should not be the primary intervention in this scenario.

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