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Questions 149

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Extract:


Question 1 of 5

The nurse is assessing the heart sounds of a client with mitral stenosis following a history of rheumatic fever. To hear a mitral murmur, the nurse should place the stethoscope at:

Correct Answer: D

Rationale: Mitral stenosis murmurs are best heard at the fourth intercostal space midclavicular line, the mitral valve area.

Question 2 of 5

A client with diabetes insipidus is receiving DDAVP (desmopressin acetate). Which lab finding indicates that the medication is having its intended effect?

Correct Answer: B

Rationale: Desmopressin increases water reabsorption, concentrating urine; a urine specific gravity of 1.020 indicates effective treatment.

Question 3 of 5

The nurse is performing discharge instruction to a client with an implantable defibrillator. What discharge instruction is essential?

Correct Answer: C

Rationale: Using a cell phone on the opposite side of the defibrillator reduces electromagnetic interference with the device.

Question 4 of 5

The nurse is preparing a middle-aged female for a total knee replacement (TKR) surgery on her left leg tomorrow. Which statement by the nurse is incorrect?

Correct Answer: C

Rationale: A fracture pan is inappropriate post-TKR; a bedpan or bedside commode is typically used. Other statements are correct.

Question 5 of 5

A client has signs of increased intracranial pressure. Which one of the following is an early indicator of deterioration in the client's condition?

Correct Answer: D

Rationale: A decrease in level of consciousness is an early and sensitive indicator of increased intracranial pressure, reflecting cerebral compromise before other signs like pupil changes or vital sign alterations.

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