Nokea
The nurse is auscultating the apical pulse over the PMI (point of maximum impact). Which heart sounds would be audible?
- A. S2 and S3
- B. S3 and S4
- C. S4 and S1
- D. S1 and S2
Correct Answer: D
Rationale: S1 (mitral/tricuspid closure) and S2 (aortic/pulmonic closure) are normally audible at the PMI. S3 and S4 are less common and indicate pathology.
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A client is being monitored using a central venous pressure monitor. If the pressure is 2 cm of water, the nurse should:
- A. Call the doctor immediately
- B. Slow the intravenous infusion
- C. Listen to the lungs for rales
- D. Administer a diuretic
Correct Answer: B
Rationale: A CVP of 2 cm of water is low, suggesting hypovolemia; slowing the IV infusion prevents fluid overload while addressing the issue.
A 17-year-old adolescent, diagnosed with schizophrenia, is admitted by the nurse to a psychiatric facility. Which behaviors would characterize this diagnosis? Select all that apply.
- A. flat affect
- B. fast speech pattern
- C. hallucinations
- D. feeling energized
Correct Answer: A,C
Rationale: Flat affect and hallucinations are hallmark symptoms of schizophrenia. Fast speech or feeling energized may occur but are not specific to this diagnosis.
Following femoral catheterization for percutaneous coronary intervention (PCI), the client has increasing pain in the catheterization site, and the nurse notes visible edema and induration surrounding the site. The nurse suspects a hematoma and notifies the physician. Which of the following interventions does the nurse anticipate? Select all that apply.
- A. Apply pressure to the site.
- B. Mark margins of edematous, indurated area.
- C. Monitor hemoglobin and hematocrit.
- D. Maintain bedrest.
- E. Administration of clotting factors.
Correct Answer: A,B,C,D
Rationale: Hematoma management includes applying pressure (A), marking edema (B), monitoring hemoglobin/hematocrit (C), and maintaining bedrest (D). Clotting factors (E) are not typically needed.
Which one of the following symptoms is common in the client with duodenal ulcers?
- A. Vomiting shortly after eating
- B. Epigastric pain following meals
- C. Frequent bouts of diarrhea
- D. Presence of blood in the stools
Correct Answer: B
Rationale: Duodenal ulcers typically cause epigastric pain 1-3 hours after meals, relieved by food or antacids.
Following surgical repair of a fractured femur, a client's hemoglobin falls to 7.4 and the physician orders one unit of packed red blood cells (250 mL) to be administered over two hours with a drop factor of 10 drops/mL. What flow rate (drops per minute) is needed? Record by rounding to the nearest whole number.
Correct Answer: 21
Rationale: To calculate the flow rate: (Volume X Drop factor)/ Time in minutes. Volume is 250 mL, drop factor is 10 drops/mL, time is 2 hours = 120 minutes. Thus, (250 X 10)/ 120 = 2,500/ 120 ≈ 20.83, rounded to 21 drops/minute.