Nokea
A student in a cardiac unit is performing auscultation of a client's heart. The nurse recognizes that the student is performing pulmonic auscultation correctly when the stethoscope is placed:
- A. Between the apex and the sternum
- B. At the fifth intercostal space at the left midclavicular line
- C. At the second intercostal space, left of the sternum
- D. At the manubrium
Correct Answer: C
Rationale: The pulmonic area is auscultated at the second intercostal space, left of the sternum, where the pulmonary valve sounds are best heard.
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The nurse is caring for a client receiving peritoneal dialysis. Which of the following assessment findings would require an intervention by the nurse?
- A. Abdominal discomfort during infusion of dialysate.
- B. Presence of constipation.
- C. Cloudy dialysate output.
- D. Ecchymosis around peritoneal catheter.
Correct Answer: C
Rationale: indicates peritonitis, also will see nausea and vomiting, anorexia, abdominal pain, tenderness, rigidity
The nurse is caring for a client who is postoperative day 2 following a total knee replacement. The client reports pain at the surgical site and has a temperature of 100.8°F (38.2°C). Which of the following actions should the nurse take FIRST?
- A. Administer an analgesic as ordered.
- B. Notify the physician.
- C. Apply a cold pack to the surgical site.
- D. Assess the surgical site for signs of infection.
Correct Answer: D
Rationale: assessing the surgical site for signs of infection is the first step to determine the cause of the fever and pain
The nurse prepares a 25-year-old woman for a cesarean section. The patient says she had major surgery several years ago and asks if she will receive a similar 'shot' before surgery. The nurse’s response should be based on an understanding that the preoperative medication given before a cesarean section
- A. contains a lower overall dosage of medication than is given before general surgery.
- B. contains reduced amounts of sedatives and hypnotics than are given before general surgery.
- C. contains reduced amounts of narcotics than are given before general surgery.
- D. contains medications similar in type and dosages to those given before general surgery.
Correct Answer: C
Rationale: decreased so less narcotic crosses the placental barrier causing respiratory depression in the infant
The nurse has an order to administer 100 units of regular insulin in 500 mL of 0.9% NS to infuse at 12 units per hour. The nurse should program the IV pump to deliver how many mLs per hour?
Correct Answer: 60
Rationale: Concentration: 100 units/500 mL = 0.2 units/mL. To deliver 12 units/hour: 12 ÷ 0.2 = 60 mL/hour.
The nurse on a physical rehabilitation unit is assigned a 63-year-old male client post-amputation of his left lower limb above the knee two weeks prior. The client has a history of peripheral vascular disease due to diabetes mellitus. Which statement by the client indicates a need for further teaching?
- A. I had my leg removed because of diabetes.
- B. My exercises are going well.
- C. My left leg hurts after I wrap my stump.
- D. I use canes to walk to the bathroom.
Correct Answer: C
Rationale: Pain after wrapping the stump may indicate improper wrapping or complications, requiring further assessment and education.