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Questions 149

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Question 1 of 5

A student in a cardiac unit is performing auscultation of a client's heart. The nurse recognizes that the student is performing pulmonic auscultation correctly when the stethoscope is placed:

Correct Answer: C

Rationale: The pulmonic area is auscultated at the second intercostal space, left of the sternum, where the pulmonary valve sounds are best heard.

Question 2 of 5

A client is 4 hours post-op left carotid endarterectomy. Which assessment finding would cause the nurse the most concern?

Correct Answer: C

Rationale: Right-sided weakness post-left carotid endarterectomy suggests a neurological deficit, possibly from stroke or hematoma, requiring immediate intervention.

Question 3 of 5

The nurse is taking the blood pressure of the obese client. If the blood pressure cuff is too small, the results will be:

Correct Answer: A

Rationale: A blood pressure cuff that is too small will result in a false elevation of the blood pressure reading due to increased pressure on the arm.

Question 4 of 5

A client is admitted to the emergency room with multiple injuries. What is the proper sequence for managing the client?

Correct Answer: C

Rationale: The ABCs of trauma care prioritize airway, breathing, and circulation. Establishing an airway comes first, followed by controlling hemorrhage and preventing shock, then assessing for head injuries.

Question 5 of 5

When caring for a client with an anterior cervical discectomy, the nurse should give priority to assessing for post-operative bleeding. The nurse should pay particular attention to:

Correct Answer: D

Rationale: Swelling in the posterior neck may indicate a hematoma, which can compress the airway or spinal cord, a critical post-operative complication.

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