Nokea
While auscultating a client's heart sounds, which description should the nurse use to document a swishing sound related to blood turbulence or valvular defect?
- A. S1 S2
- B. S1 S2 S3
- C. Murmur
- D. Pericardial friction rub
Correct Answer: C
Rationale: The correct answer is 'C: Murmur.' A murmur is auscultated as a swishing sound associated with blood turbulence caused by the heart or a valvular defect. Choices 'A: S1 S2' and 'B: S1 S2 S3' refer to normal heart sounds, specifically the closure of heart valves. 'D: Pericardial friction rub' is a dry, rubbing or grating sound caused by inflammation of the pericardial sac and is not associated with blood flow or valvular issues.
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The nurse is assessing a female client's blood pressure because she reported feeling dizzy. The blood pressure cuff is inflated to 140 mm Hg and as soon as the cuff is deflated a Korotkoff sound is heard. Which intervention should the nurse implement next?
- A. Wait 1 minute and palpate the systolic pressure before auscultating again.
- B. Increase the inflation pressure by 20 mm Hg and measure again.
- C. Switch to a larger cuff and repeat the measurement.
- D. Document the finding as normal.
Correct Answer: A
Rationale: If a Korotkoff sound is heard immediately upon deflation, it may indicate an inaccurate reading. Waiting and palpating the systolic pressure can help confirm the accuracy of the measurement. Choice A is the correct intervention because it allows the nurse to ensure the accuracy of the blood pressure reading. Choice B is incorrect as increasing the inflation pressure is not necessary in this situation. Choice C is also incorrect as switching to a larger cuff is not warranted based on the information provided. Choice D is incorrect because documenting the finding as normal without further verification could lead to inaccurate information.
The nurse is caring for a client with a tracheostomy who has thick, tenacious secretions. Which assessment finding requires immediate intervention?
- A. Crepitus around the tracheostomy site
- B. Dry and cracked tracheostomy site
- C. Mucous plugging of the tracheostomy tube
- D. Yellowing of the skin around the tracheostomy site
Correct Answer: C
Rationale: Mucous plugging of the tracheostomy tube is the most concerning assessment finding in a client with a tracheostomy. It can lead to airway obstruction, which requires immediate intervention to ensure the client's airway remains patent. Crepitus around the tracheostomy site may indicate subcutaneous emphysema but is not as urgent as a blocked airway. A dry and cracked tracheostomy site may indicate poor skin integrity but does not pose an immediate threat to the client's airway. Yellowing of the skin around the tracheostomy site could suggest a localized infection, but it is not as critical as a potential airway obstruction caused by mucous plugging.
Which instruction is most important for a client who receives a new plan of care to treat osteoporosis?
- A. Start a weight-bearing exercise plan.
- B. Increase consumption of foods rich in calcium.
- C. Arrange a bone density test every year.
- D. Stay upright after taking the medication.
Correct Answer: D
Rationale: The correct answer is D: 'Stay upright after taking the medication.' This instruction is crucial for clients receiving medications like bisphosphonates to prevent esophageal irritation or erosion. While weight-bearing exercises (choice A) are important for bone health, staying upright after medication intake takes precedence. Increasing calcium-rich foods (choice B) is beneficial but not the most important immediate instruction. Scheduling bone density tests (choice C) is necessary for monitoring osteoporosis but is not as critical as staying upright after medication.
The nurse needs to add a medication to a liter of 5% Dextrose in Water (D5W) that is already infusing into a client. At what location should the nurse inject the medication?
- A. Medication port
- B. IV drip chamber
- C. Y-site connector
- D. At the hub of the IV catheter
Correct Answer: A
Rationale: The correct answer is the medication port. When adding medication to an already infusing IV solution, it should be done through the medication port to ensure direct delivery into the bloodstream without interrupting the primary IV line. Injecting the medication into the IV drip chamber, Y-site connector, or at the hub of the IV catheter can lead to dilution, inaccurate dosing, or potential blockages in the IV line, which can compromise the effectiveness of the medication and patient safety.
A client with chronic kidney disease (CKD) is admitted with hyperkalemia. Which assessment finding is most concerning?
- A. Bradycardia
- B. Muscle weakness
- C. Peaked T waves on the ECG
- D. Decreased deep tendon reflexes
Correct Answer: C
Rationale: The correct answer is C: Peaked T waves on the ECG. In hyperkalemia, elevated potassium levels can affect the heart's electrical activity, leading to changes on the ECG such as peaked T waves. This finding is concerning as it can progress to serious cardiac arrhythmias, including ventricular tachycardia and fibrillation. Bradycardia (choice A) and decreased deep tendon reflexes (choice D) are not typically associated with hyperkalemia. While muscle weakness (choice B) can occur in hyperkalemia due to its effect on neuromuscular function, the most concerning assessment finding indicating the need for immediate intervention in this scenario is peaked T waves on the ECG.