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Questions 164

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Extract:


Question 1 of 5

The nurse auscultates the heart sounds of a 77-year-old client with chronic heart failure. Which heart sound should the nurse document?

Correct Answer: C

Rationale: An S3 heart sound is commonly associated with heart failure due to fluid overload and ventricular dysfunction.

Question 2 of 5

Which of the following medications is not considered a neuromuscular blocker?

Correct Answer: C

Rationale: Pitressin is a hormone replacement medication.

Question 3 of 5

A client is admitted with a pressure ulcer in the sacral area. The partial thickness wound is 4 cm by 7 cm, the wound base is red and moist with no exudate and the surrounding skin is intact. Which of the following coverings is most appropriate for this wound?

Correct Answer: D

Rationale: Occlusive moist dressing. This supports healing by maintaining a moist environment for granulation tissue.

Question 4 of 5

The pediatric nurse receives report on 4 clients. Which client should the nurse see first?

Correct Answer: B

Rationale: The 6-year-old post-bronchoscopy is at risk for airway complications and requires immediate assessment.

Question 5 of 5

The nurse is to observe the client for shock. The client's admitting vital signs are blood pressure (BP)=116/70, pulse=86, and respirations=24. Which finding, if observed, would be most suggestive of shock?

Correct Answer: B

Rationale: Increased pulse (tachycardia) is a hallmark of shock, compensating for reduced volume. Stable or slightly varied BP and low pulse are less indicative.

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