Nokea
A nurse is preparing to listen to the apical heart rate in the area of the mitral valve in an adult client. The nurse should place the stethoscope on which part of the client's chest?
- A. Second left interspace
- B. Second right interspace
- C. Left lower sternal border
- D. Fifth left interspace at the midclavicular line
Correct Answer: D
Rationale: The correct placement for auscultating the apical heart rate in the area of the mitral valve is the fifth left interspace at the midclavicular line. Placing the stethoscope in the second left interspace would be to listen to the pulmonic valve, the second right interspace is for the aortic valve, and the left lower sternal border is for the tricuspid valve.
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When caring for an elderly client and providing education, which of the following would be the least appropriate for the nurse to do?
- A. The nurse speaks loudly.
- B. The nurse allows additional time after each instruction to allow the client to process.
- C. The nurse provides supplemental written resources.
- D. The nurse breaks up the education into multiple shorter sessions.
Correct Answer: A
Rationale: Speaking loudly is inappropriate when caring for an elderly client. It is essential to assess the client for a hearing impairment and provide appropriate assistance if needed. Elderly clients may require more time to process information due to slower reaction times, benefit from shorter sessions as they fatigue easily, and can absorb supplemental written resources effectively. Therefore, speaking loudly may not be conducive to effective communication and may not cater to the specific needs of the elderly client, unlike the other options provided.
During an interview, what action should a nurse conducting an interview with a client take to collect subjective data?
- A. Takes minimal notes to avoid impeding observation of the client's nonverbal behaviors
- B. Takes a great deal of notes to allow the client to continue at his or her own pace as the nurse records what he or she is saying
- C. Takes notes because this allows the nurse to break eye contact with the client, which may increase the client's level of comfort
- D. Takes notes to allow the nurse to shift attention away from the client, which may make the nurse more comfortable
Correct Answer: A
Rationale: During an interview, a nurse should minimize note-taking to focus on the client and not impede the conversation. Taking minimal notes allows the nurse to effectively observe the client's nonverbal behaviors, which provide valuable subjective data. Option B, taking many notes, is incorrect as it can distract the nurse from the client's cues and hinder interaction. Option C, taking notes to break eye contact, is incorrect as it may decrease the client's comfort level and disrupt communication. Option D, taking notes to shift attention away from the client, is incorrect as it diminishes the client's importance and may make them uncomfortable during sensitive discussions. Therefore, the correct approach is for the nurse to take minimal notes, ensuring effective observation of the client's nonverbal behaviors while collecting subjective data.
A chemical reaction between drugs prior to their administration or absorption is known as:
- A. a drug incompatibility
- B. a side effect
- C. an adverse event
- D. an allergic response
Correct Answer: A
Rationale: A drug incompatibility occurs when drugs react chemically before administration, potentially reducing efficacy or causing harm. Side effects and adverse events occur post-administration, and allergic responses are immune-mediated.
A nurse is preparing to measure a client's calf circumference. The nurse performs this procedure by performing which action?
- A. Placing a tape measure around the widest point of the lower leg
- B. Measuring 2 inches above the knee and placing the tape measure around the client's leg at this point
- C. Measuring 2 inches above the ankle and placing the tape measure around the client's leg at this point
- D. Measuring 2 inches below the patella and placing the tape measure around the client's leg at this point
Correct Answer: A
Rationale: To measure a client's calf circumference accurately, a nurse should place a non-stretchable tape measure around the widest point of the lower leg. It is crucial to ensure that the tape measure is positioned at the same number of centimeters down from a specific landmark, such as the patella, on both legs for consistency. Placing the tape measure 2 inches above the knee (Option B), 2 inches above the ankle (Option C), or 2 inches below the patella (Option D) would not provide an accurate measurement of the calf circumference. Therefore, these options are incorrect choices.
A nurse in the emergency department is assisting with data collection of a client. The presence of which condition would cause the nurse to avoid testing range of motion (ROM) of the cervical spine?
- A. Headache
- B. Neck trauma
- C. Sinus infection
- D. Muscle spasms
Correct Answer: B
Rationale: A nurse assisting with data collection for a client should avoid testing the range of motion (ROM) of the cervical spine if the client has neck trauma. Neck trauma may have resulted in a cervical fracture, and further movement of the neck could lead to spinal cord injury. Testing ROM does not need to be avoided for headache, sinus infection, or muscle spasms as these conditions do not pose the same risk of exacerbating a potential cervical injury. Therefore, the correct answer is neck trauma.