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Which of the following assessment findings are consistent with aortic stenosis?
- A. Systolic click
- B. Pitting edema
- C. Harsh systolic crescendo decrescendo murmur
- D. Atrial fibrillation
Correct Answer: C
Rationale: Aortic stenosis narrows the valve, obstructing outflow producing a harsh systolic crescendo-decrescendo murmur, loudest at the aortic area, a classic sign from turbulent flow. Systolic clicks tie to mitral prolapse, not stenosis. Pitting edema reflects heart failure, a late complication, not direct. Atrial fibrillation may coexist but isn't specific. Nurses expect this murmur, auscultating for its distinct pattern, key to spotting stenosis early, guiding diagnostics like echocardiography to prevent progression to failure.
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The nurse receives an order to infuse heparin 1200 units/hr IV. The IV bag contains 25,000 units heparin in 500 mL D5W. Calculate the IV rate in mL/hr.
- A. 20
- B. 24
- C. 28
- D. 30
Correct Answer: B
Rationale: Heparin's drip: 1200 units/hr from 25,000 units in 500 mL 500 ÷ 25,000 = 0.02 mL/unit, times 1200 = 24 mL/hr, a nurse's calc to thin blood right. Off numbers (20, 28, 30) skew dosing. Precision keeps clots at bay, a steady flow in this IV dance.
A client is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important?
- A. Assessing the IV site every hour
- B. Educating the client on side effects
- C. Monitoring the client for nausea
- D. Providing warm packs for comfort
Correct Answer: A
Rationale: Chemotherapy drugs administered via peripheral IV can be vesicants, meaning they can cause severe tissue damage if they leak (extravasate) into surrounding tissues. Peripheral lines are more prone to this than central lines due to smaller vein size and less secure placement. Assessing the IV site hourly or per facility policy is the most important action to prevent extravasation, ensuring the line remains patent and no swelling, redness, or pain develops. Early detection allows prompt intervention, like stopping the infusion, to minimize harm. Educating about side effects and monitoring for nausea are key aspects of care but address systemic effects, not the immediate risk of local tissue injury. Warm packs might soothe discomfort but could worsen damage if extravasation occurs. Prioritizing IV site assessment reflects the nurse's role in safety and prevention, critical in oncology where chemotherapy's potency demands vigilant monitoring to protect the client from serious complications.
A nurse is caring for a client who presented to the emergency department with complaints of fatigue, palpitations, and chest pains. Upon assessment, the provider notes an S3 and S4 gallop, weak peripheral pulses, and tachycardia. The provider orders a chest x-ray and echocardiogram, which reveals left ventricular dilation. Which of the following disorder is consistent with these findings?
- A. Cardiac tamponade
- B. Dilated cardiomyopathy
- C. Pericarditis
- D. Restrictive cardiomyopathy
Correct Answer: B
Rationale: Left ventricular dilation with S3, S4, weak pulses, and tachycardia paints dilated cardiomyopathy heart muscle stretches, weakening pump, causing fatigue and palpitations. Tamponade compresses, not dilates. Pericarditis inflames without dilation. Restrictive stiffens, resisting stretch. Nurses tie this to DCM's systolic flop, anticipating meds like ACE inhibitors, a fit for this stretched-out heart.
The nursing instructor explains the difference between normal cells and benign tumor cells. What information does the instructor provide about these cells?
- A. Benign tumors grow through invasion of other tissue.
- B. Benign tumors have lost their cellular regulation from contact inhibition.
- C. Growing in the wrong place or time is typical of benign tumors.
- D. The loss of characteristics of the parent cells is called anaplasia.
Correct Answer: C
Rationale: Benign tumors are fundamentally different from malignant tumors in their behavior and characteristics. Unlike malignant tumors, which invade surrounding tissues, benign tumors do not grow through invasion but rather through hyperplasia, a controlled increase in cell number. They retain contact inhibition, a regulatory mechanism where normal cells stop dividing when they touch each other, preventing uncontrolled growth. The defining feature of benign tumors is that they consist of cells that are essentially normal but are growing in an inappropriate location or at an incorrect time, such as a lipoma in fatty tissue. Anaplasia, on the other hand, refers to the loss of differentiation and is a hallmark of malignant cancer cells, not benign ones. Thus, the instructor would emphasize that benign tumors are misplaced normal cells, making this the accurate statement. This distinction is critical for nursing students to understand, as it impacts diagnosis, treatment decisions, and patient education regarding the non-threatening nature of benign tumors compared to cancerous growths.
In the UK, orthognathic surgery is likely to:
- A. Be undertaken in specialist craniofacial surgery units rather than in maxillofacial surgery units.
- B. Be associated with a high incidence of postoperative nausea and vomiting.
- C. Require a nasal rather than an oral tracheal tube when a Le Fort I osteotomy is performed.
- D. Require admission of the patient to a high-dependency unit.
Correct Answer: B
Rationale: Orthognathic surgery corrects jaw deformities in the UK, typically by maxillofacial surgeons, not solely craniofacial units (reserved for complex congenital cases). Postoperative nausea and vomiting (PONV) are common due to blood swallowing, prolonged surgery, and opioids risk factors per Apfel criteria. Le Fort I osteotomy (maxillary) often uses oral intubation; nasal tubes suit mandibular focus or surgeon preference, not a requirement. High-dependency unit (HDU) admission isn't routine most recover in general wards unless complications (e.g., airway) arise. Cleft palate repair precedes, not follows, orthognathic work. PONV's prevalence reflects surgical and anaesthetic challenges, necessitating robust antiemetic prophylaxis.