Concepts for Nursing Practice Test Bank

Questions 14

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Concepts for Nursing Practice Test Bank Questions

Question 1 of 5

The nurse is preparing to conduct a cardiac assessment for a pediatric client. Which location will the nurse use when auscultating the apical pulse?

Correct Answer: A

Rationale: When auscultating the apical pulse in pediatric clients, the nurse should place the stethoscope at the fifth intercostal space at the midclavicular line. This location is where the apex of the heart is located in pediatric clients and provides the most accurate assessment of the apical pulse. Placing the stethoscope at the left nipple (B) or right nipple (C) would not provide an accurate assessment of the apical pulse location. Auscultating at the eighth intercostal space (D) would be too low and not capture the apical pulse accurately.

Question 2 of 5

The nurse is performing an assessment of a client. Which should the nurse recognize as a noncardiac risk factor for heart failure?

Correct Answer: C

Rationale: Hyperthyroidism is a noncardiac risk factor for heart failure because it can lead to increased heart rate, palpitations, and ultimately strain on the heart. When a person has hyperthyroidism, the thyroid gland produces too much thyroid hormone, which can impact the cardiovascular system by affecting heart function. This increased workload on the heart can contribute to the development of heart failure. It is important for the nurse to recognize hyperthyroidism as a potential risk factor for heart failure during the assessment of the client.

Question 3 of 5

A nurse working in the emergency department is participating in the resuscitation of a client experiencing sudden cardiac death. After five cycles of CPR, the nurse evaluates the client's cardiac rhythm as asystole. What is the next action by the nurse?

Correct Answer: B

Rationale: Asystole is the absence of any cardiac electrical activity, and it is a non-shockable rhythm. In the case of asystole, defibrillation would not be effective. The next appropriate action would be to continue high-quality CPR and administer epinephrine according to the advanced cardiac life support (ACLS) protocol. Additionally, assessing the client's pulse is crucial to determine if there is any return of spontaneous circulation (ROSC) following CPR and medication administration. Checking the cardiac monitor electrodes ensures proper attachment and accurate monitoring of the client's cardiac rhythm but may not directly impact the management of asystole.

Question 4 of 5

The nurse is conducting a health history with a patient that focuses on the endocrine system. Which question should the nurse include in this assessment?

Correct Answer: B

Rationale: The nurse should include the question "Have you noticed a change in your thirst?" in the health history focusing on the endocrine system because changes in thirst can be indicative of conditions such as diabetes insipidus or diabetes mellitus that affect the endocrine system. Thirst can be altered due to changes in hormone levels, particularly those related to water balance and blood sugar regulation. Monitoring changes in thirst can provide important information about potential endocrine imbalances in the body. Asking about changes in thirst is relevant to assessing the patient's endocrine health in this context.

Question 5 of 5

The nurse is evaluating the teaching provided to a patient with acute glomerulonephritis. Which patient action indicates that additional teaching is not necessary?

Correct Answer: B

Rationale: Option B, "Demonstrates care of the vascular access device for dialysis," indicates that the patient understands how to care for their vascular access device, which is important for receiving dialysis treatment. This action shows adequate comprehension and competency in managing this aspect of their care. Therefore, additional teaching is not necessary in this area. On the other hand, options A, C, and D present actions that may require further clarification or reinforcement in the teaching provided to the patient with acute glomerulonephritis.

Similar Questions

The nurse is evaluating the teaching provided to a patient with acute glomerulonephritis. Which patient action indicates that additional teaching is not necessary?
The nurse is preparing to conduct a cardiac assessment for a pediatric client. Which location will the nurse use when auscultating the apical pulse?
The nurse is preparing instructional materials for a patient recovering from a fractured leg. What mineral should the nurse teach as being essential in bone healing?
During the health history of an older male patient, the nurse focuses on the gland that encircles the male urethra at the base of the bladder. On which organ is the nurse focusing?
The mother of a baby born with a congenital heart defect is upset, as no one else in the family has been born with this condition. To determine the cause of the defect, which question is appropriate for the nurse to ask the mother?

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