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During a peripheral vascular assessment, a healthcare professional places the bell of the stethoscope on a client's neck and hears an audible vascular sound associated with turbulent blood flow. This sound indicates which of the following?
- A. Narrowed arterial lumen
- B. Distended jugular veins
- C. Impaired ventricular contraction
- D. Asynchronous closure of the aortic and pulmonic valve
Correct Answer: A
Rationale: The correct answer is A: Narrowed arterial lumen. Arterial bruits are abnormal sounds caused by turbulent blood flow through narrowed or occluded arteries. This turbulent flow creates a blowing sound, which is heard as an arterial bruit. Distended jugular veins (choice B) are typically associated with venous issues, not arterial abnormalities. Impaired ventricular contraction (choice C) and asynchronous closure of the aortic and pulmonic valve (choice D) are not directly related to the audible vascular sound described in the scenario.
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While measuring a client's vital signs, the nurse notices an irregularity in the heart rate. Which nursing action is appropriate?
- A. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart
- B. Measure the blood pressure
- C. Perform an ECG
- D. Recheck the heart rate after 5 minutes
Correct Answer: A
Rationale: The appropriate nursing action when an irregularity in the heart rate is observed is to count the apical pulse rate for a full minute and describe the rhythm in the chart. This approach helps in obtaining an accurate assessment of the irregularities present. Measuring the blood pressure (Choice B) is important but not the immediate priority when an irregular heart rate is noted. Performing an ECG (Choice C) may be necessary but is a more advanced intervention that should follow the initial assessment. Rechecking the heart rate after 5 minutes (Choice D) may delay potential interventions for addressing the irregularity, making it less appropriate than the immediate assessment and documentation of the pulse rhythm.
Before donning gloves to perform a procedure, proper hand hygiene is essential. The healthcare professional understands that the most important aspect of hand hygiene is the amount of:
- A. Temperature
- B. Time
- C. Friction
- D. Soap
Correct Answer: C
Rationale: The correct answer is C: Friction. The amount of friction is crucial in effective hand hygiene to remove microorganisms. Rubbing hands together with friction helps to dislodge and remove dirt, oils, and microorganisms. While temperature and soap are important factors in hand hygiene, the mechanical action of friction plays a more significant role in physically removing contaminants. Time is also important in hand hygiene practice, but without adequate friction, the effectiveness of the process is compromised.
A policy requiring the removal of acrylic nails by all nursing personnel was implemented 6 months ago. Which assessment measure best determines if the intended outcome of the policy is being achieved?
- A. Number of staff-induced injuries
- B. Client satisfaction survey
- C. Healthcare-associated infection rate
- D. Rate of needle-stick injuries by nurses
Correct Answer: C
Rationale: The correct answer is C: Healthcare-associated infection rate. This measure best indicates the effect of the policy on infection control. By monitoring the healthcare-associated infection rate, it can be determined if the policy of removing acrylic nails has contributed to reducing the risk of infections. Choices A, B, and D are not as directly linked to the outcome of the policy. The number of staff-induced injuries may not be solely due to acrylic nails. Client satisfaction may not be directly impacted by this policy, and needle-stick injuries are more related to a different aspect of healthcare practice.
While caring for an older adult client who is violent and attempting to disconnect her IV lines, the provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints?
- A. Remove the restraints one at a time
- B. Secure the restraints tightly to prevent movement
- C. Check the restraints every hour
- D. Use leather restraints for additional security
Correct Answer: A
Rationale: Removing restraints one at a time is the correct action to take when caring for a client in soft wrist restraints. This approach ensures safety and comfort while still maintaining the necessary restrictions. Choice B is incorrect as securing the restraints tightly can lead to circulatory issues and discomfort. Choice C of checking the restraints every hour is a reasonable action, but it is not the priority when compared to the correct choice of removing the restraints one at a time. Choice D of using leather restraints for additional security is unnecessary and may be more restrictive and uncomfortable for the client.
What action should the LPN/LVN take to prevent postoperative complications in a client who has undergone abdominal surgery?
- A. Encourage the client to use an incentive spirometer regularly.
- B. Assist the client in ambulating as soon as possible.
- C. Position the client in high Fowler's position.
- D. Encourage the client to cough and deep breathe regularly.
Correct Answer: A
Rationale: Encouraging the client to use an incentive spirometer regularly is crucial in preventing postoperative complications after abdominal surgery. This action helps prevent atelectasis by promoting lung expansion and improving air exchange in the lungs, reducing the risk of respiratory complications. Assisting the client in ambulating early is important for preventing issues like deep vein thrombosis but may not directly address respiratory concerns postoperatively. Positioning the client in high Fowler's position can help with respiratory distress but is not as specific to preventing postoperative respiratory complications as using an incentive spirometer. While encouraging the client to cough and deep breathe is generally beneficial for lung expansion, using an incentive spirometer is more effective and targeted in preventing atelectasis after abdominal surgery.