Nokea
The nurse is told in report that the client has aortic stenosis. Which anatomical position should the nurse auscultate to assess the murmur?
- A. Second intercostal space, right sternal border
- B. Erb's point
- C. Second intercostal space, left sternal border
- D. Fourth intercostal space, left sternal border
Correct Answer: A
Rationale: The correct anatomical position for auscultating the murmur of aortic stenosis is the second intercostal space, right sternal border. This is where the aortic valve is best auscultated, and the murmur of aortic stenosis is heard most clearly. Choices B, C, and D are incorrect as the murmur of aortic stenosis is best heard at the second intercostal space on the right side of the sternum.
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Which of the following is a primary factor that affects blood pressure?
- A. Obesity
- B. Age
- C. Stress
- D. Gender
Correct Answer: A
Rationale: Obesity is a primary factor that affects blood pressure. Excess body weight, especially when concentrated around the abdomen, can increase the risk of hypertension (high blood pressure) as it puts extra strain on the heart to pump blood around the body. This can lead to various cardiovascular complications and other health issues. Managing weight through a healthy diet and regular physical activity can help control blood pressure levels. Age, stress, and gender can also influence blood pressure, but obesity has a more direct and significant impact on increasing blood pressure levels compared to the other factors listed.
Which nursing action(s) can result in disciplinary action by state boards of nursing?
- A. Release of client health information to a client's neighbor
- B. Delegation of a dressing change to unlicensed assistive personnel (UAP)
- C. Release of client health information to the client's durable power of attorney
- D. A, B
Correct Answer: D
Rationale: The correct answer is D. Disclosing client health information to unauthorized individuals, such as a client's neighbor (choice A) or improper delegation of nursing tasks to unlicensed personnel like UAPs (choice B), are violations of patient confidentiality and safety. Releasing client health information to the client's durable power of attorney (choice C) is a legal and appropriate action, not warranting disciplinary action. Therefore, choices A and B can result in disciplinary action by state boards of nursing, making option D the correct answer.
In supply and equipment management, what is the FIRST step in the procurement process?
- A. Keep hand receipts up to date
- B. Establish requirements
- C. Requisition supplies and equipment through the proper channels
- D. Properly receive, inspect, and store required items
Correct Answer: B
Rationale: In the procurement process, the FIRST step is to establish requirements. This step involves identifying and defining the needs for supplies and equipment before moving forward with the procurement process. Keeping hand receipts up to date (Choice A) is a task related to tracking and managing inventory but comes after the requirements have been established. Requisitioning supplies and equipment (Choice C) and receiving, inspecting, and storing items (Choice D) are subsequent steps in the procurement process that follow after the requirements have been determined.
A patient with chronic renal failure should avoid which of the following?
- A. Potassium
- B. Calcium
- C. Iron
- D. Zinc
Correct Answer: A
Rationale: Patients with chronic renal failure should avoid potassium due to impaired kidney function. The kidneys may not effectively filter excess potassium from the blood, leading to hyperkalemia. Calcium, iron, and zinc do not need to be avoided specifically in chronic renal failure unless there are other underlying reasons or complications.
The nurse supervises care of a client who is receiving enteral feeding via a nasogastric tube. The nurse determines that care is appropriate if which of the following is observed? (Select all that apply)
- A. The nursing assistant aspirates and measures the amount of gastric aspirate
- B. The nursing assistant elevates the head of the client's bed 30 degrees
- C. The nursing assistant warms the formula to room temperature
- D. B, C
Correct Answer: D
Rationale: The correct answer is D because elevating the head of the bed reduces the risk of aspiration, and warming the formula to room temperature helps prevent discomfort and complications. Choice A is incorrect as only licensed healthcare professionals should aspirate and measure the amount of gastric aspirate. Choice B is correct as it helps prevent aspiration. Choice C is correct as warming the formula can prevent discomfort.