Nokea
A client with aortic stenosis complains of increasing dyspnea and dizziness. Identify the area where the nurse would place the stethoscope to assess a murmur from aortic stenosis.
- A. 1
- B. 2
- C. 3
- D. 4
- E. 5
Correct Answer: A
Rationale: The stethoscope is placed at the second intercostal space right of sternum (1) to assess the aortic area. (2) is the pulmonic valve area, (3) is Erb’s point, (4) is the Tricuspid valve area, and (5) is the Mitral valve area.
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An airplane crash results in mass casualties. The nurse is directing personnel to tag all victims. Which is normal should be placed on the tag? Select all that apply.
- A. Triage priority.
- B. Identifying information when possible (such as name, age, and address).
- C. Medications and treatments administered.
- D. Presence of jewelry.
- E. Next of kin.
Correct Answer: A,B,C
Rationale: Victim tags should include triage priority, identifying information, and treatments administered to ensure proper care and identification. Jewelry and next of kin are secondary considerations.
How often should the postoperative client's temperature be assessed during the first 24 hours after surgery?
- A. Every 2 hours.
- B. Every 4 hours.
- C. Every 6 hours.
- D. Every 8 hours.
Correct Answer: B
Rationale: Assessing temperature every 4 hours in the first 24 hours detects fever early, indicating potential infection or other complications.
Which of the following activities should the nurse teach the client to implement after the removal of nasal packing on the second postoperative day?
- A. Avoid cleaning the nares until swelling has subsided.
- B. Apply water-soluble jelly to lubricate the nares.
- C. Keep a nasal drip pad in place to absorb secretions.
- D. Use a bulb syringe to gently irrigate nares.
Correct Answer: B
Rationale: Applying water-soluble jelly lubricates the nares, preventing crusting and discomfort post-packing removal. Cleaning is safe once packing is removed. A drip pad is unnecessary unless bleeding persists. Irrigation with a bulb syringe is not standard care.
Which finding indicates effective hemodialysis?
- A. Decreased BUN.
- B. Increased potassium.
- C. Weight gain.
- D. Hypotension.
Correct Answer: A
Rationale: Decreased BUN indicates effective removal of waste products.
The nurse should do which of the following to decrease a female client's anxiety about being placed in the lithotomy position for surgery?
- A. Explain in detail what will occur in the operating room.
- B. Determine what the client is concerned about.
- C. Pad the stirrups for comfort.
- D. Reassure the client that an all-female surgical team will be present.
Correct Answer: B
Rationale: Determining the client's specific concerns about the lithotomy position allows the nurse to address her anxiety directly, promoting trust and tailored reassurance.