Nokea
The nurse is caring for a newborn with patent ductus arteriosus. Which finding would be consistent with the condition?
- A. Blowing diastolic murmur
- B. Harsh systolic murmur
- C. Loud machine-like murmur
- D. Systolic ejection murmur
Correct Answer: C
Rationale: Patent ductus arteriosus causes a loud, machine-like murmur (C) due to continuous blood flow. Other murmurs (A, B, D) are associated with different cardiac conditions.
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The nurse has delegated the task of taking the temperature of a client with a new tympanic thermometer to a certified nursing assistant. The nursing assistant says, 'This looks easy. I am good at figuring things out.' What is the nurse's responsibility?
- A. Allow the nursing assistant to proceed.
- B. Assign the task to another nursing assistant.
- C. Ask another nursing assistant to demonstrate this task to the nursing assistant.
- D. Demonstrate the proper use of the thermometer and observe the nursing assistant.
Correct Answer: D
Rationale: Demonstrating and observing ensures the CNA uses the tympanic thermometer correctly, maintaining accuracy and safety.
The nurse supporting a family who has just experienced a sudden and unexpected death needs to know:
- A. that survivors have greater emotional turmoil and shock than when death is expected.
- B. that survivors have less emotional turmoil and shock than when death is expected.
- C. that survivors have the same emotional turmoil and shock as when death is expected.
- D. that survivors have little emotional turmoil and shock because they were not there.
Correct Answer: A
Rationale: Sudden death produces greater emotional turmoil and shock in survivors than does a gradual, expected death.
One month ago, a client was prescribed phenytoin 100 mg orally 3 times daily. The client's current serum phenytoin level is 32 mcg/mL (127 μmol/L). Which action by the health care provider does the nurse anticipate?
- A. Administer phenytoin as prescribed
- B. Decrease phenytoin daily dose
- C. Increase phenytoin daily dose
- D. Repeat serum phenytoin level in 2 hours
Correct Answer: B
Rationale: A phenytoin level of 32 mcg/mL is toxic (therapeutic range: 10-20 mcg/mL), so the dose should be decreased (B). Continuing (A) or increasing (C) the dose risks toxicity. Repeating the level (D) delays intervention.
The student nurse verbalizes the procedure for obtaining a wound culture to the nurse preceptor. Which of the following statements by the student indicate a correct understanding?
- A. I will apply the prescribed bacitracin ointment after collecting the wound culture.
- B. I will cleanse the wound by gently flushing it with normal saline.
- C. I will obtain a sample of the drainage accumulated since the last dressing change.
- D. I will perform hand hygiene and apply new gloves before obtaining the wound culture.
- E. I will swab the wound from the outermost margin toward the center.
Correct Answer: B,D
Rationale: Cleansing the wound with normal saline (B) removes contaminants, and hand hygiene with gloves (D) ensures sterility. Applying ointment before the culture (A) could contaminate the sample. Swabbing from the outermost margin to the center (E) risks contaminating the sample with skin flora; the correct method is to swab the cleanest area first. Obtaining drainage since the last dressing change (C) may not target active infection.
The nurse recognizes that it is acceptable for which pair of clients to be assigned to share a semi-private room?
- A. 35-year-old with blood loss anemia and a 28-year-old diagnosed with severe anorexia nervosa
- B. 50-year-old who had a bowel resection 2 days ago and a 40-year-old diagnosed with pneumonia
- C. 60-year-old who had a total hip arthroplasty yesterday and a 58-year-old with fever of unknown origin
- D. 60-year-old with gastroenteritis and a 70-year-old with diarrhea and vomiting related to chemotherapy
Correct Answer: D
Rationale: Clients with gastroenteritis and chemotherapy-induced diarrhea (D) have similar non-airborne conditions, making them suitable roommates. Pneumonia (B) and fever of unknown origin (C) pose infection risks. Anemia and anorexia (A) are unrelated but not optimal.