Where should a nurse auscultate the apex beat?

Correct Answer: A

Rationale: The correct location to auscultate the apex beat is at the fifth intercostal space, along the midclavicular line. This is where the apical impulse, also known as the point of maximal impulse (PMI), can be best heard. Choices B, C, and D are incorrect anatomical locations for auscultating the apex beat, which makes them incorrect choices. Auscultating at the correct location allows healthcare providers to assess the heart's function and detect any abnormalities in heart sounds, which is crucial for comprehensive patient care.

Correct Answer: B

Rationale: The correct answer is B: Hamburger, fries, and soft drink. This meal is considered the least nutritious among the options provided due to its high content of unhealthy fats, processed carbohydrates, and added sugars, which lack essential nutrients. On the other hand, choice A: Ham sandwich, apple, and milk, offers a balanced meal with protein, fiber, vitamins, and calcium. Choice C: Macaroni and cheese, green beans, and peaches, provides a mixture of carbohydrates, vegetables, and fruits. Choice D: Meatloaf, broccoli, and pear slices, includes protein, fiber, and vitamins. Thus, all choices except B provide a more balanced and nutritious meal.

Correct Answer: A

Rationale: The correct answer is Orthopnea. Orthopnea is a medical condition in which a person has difficulty breathing while lying down. To alleviate this difficulty, the person may need to sit, stand, or use multiple pillows. On the other hand, Dyspnea refers to general shortness of breath which is not specifically related to the position of the body. Eupnea is the term for normal, unlabored breathing, and Apnea is a condition characterized by the cessation of breathing. Thus, none of these other choices directly relate to the need to adjust body position or use aids like multiple pillows to breathe comfortably when lying down.

Correct Answer: C

Rationale: The correct answer is C. While it is true that Mrs. Guevarra is delegating tasks to the nurse-aide, she does not necessarily have to directly supervise or evaluate the aide. She still retains the overall accountability for the care of the client, but direct supervision of the aide is not a requirement for delegation. Choice A is incorrect because the primary purpose of delegation is not instruction. Choice B is also incorrect because although Mrs. Guevarra is delegating tasks, she still retains accountability for those tasks. Finally, choice D is incorrect because the ability to perform the task being delegated is not a requirement for the delegator; the delegatee should have the necessary skills and knowledge to perform the delegated tasks.

Correct Answer: C

Rationale: Heparinizing the shunt daily (choice C) is the highest priority action as it prevents the formation of blood clots that can occlude the shunt, leading to potential complications such as thrombosis. Avoiding taking blood pressure or blood samples from the arm with the shunt (choice A) is also important, but secondary to heparinizing the shunt. Similarly, instructing the patient not to exercise the arm with the shunt (choice B) can help prevent unnecessary strain on the shunt, but it is not as critical as preventing clot formation. Changing the dressing of the shunt daily (choice D) is a standard nursing care practice to prevent infection, but again, it is not as critical as ensuring the shunt remains patent through daily heparinization.

Correct Answer: D

Rationale: The correct answer is 'Termination'. This phase of the therapeutic relationship is when the nurse informs the patient about the conclusion of therapy. It is during this phase that the nurse and the patient review the goals and progress made and also discuss the upcoming termination. The other phases are not the appropriate times for discussing termination. 'Pre-orientation' is the phase before the nurse-patient relationship is established; 'Orientation' is when the nurse and patient get to know each other and set goals; and 'Working' is when these goals are pursued. Therefore, choices A, B, and C are incorrect.

Correct Answer: A

Rationale: The correct answer is 'A', which says trim nails using a nail clipper. This is incorrect because patients with peripheral vascular disease, particularly those caused by diabetes, should not trim their nails themselves due to the risk of injury, infection, and poor wound healing. The other options, 'B', 'C', and 'D', are correct advice for diabetic foot care. Applying cornstarch can help keep the feet dry and prevent fungal infections. Checking the water temperature before bathing can prevent burns, as patients with peripheral vascular disease often have decreased sensation in their feet. Wearing canvas shoes can improve foot ventilation and reduce the risk of foot ulcers and infections.

Correct Answer: C

Rationale: Fortified soy milk is a reliable source of vitamin B12 for pregnant vegan clients as it is usually enriched with this vitamin. The other options, while nutritious, are not reliable sources of B12 for vegans. Soybeans may not provide enough B12, algae contains B12 analogs that the human body cannot utilize, and the B12 content in sea vegetables can fluctuate, potentially not providing the necessary daily intake.

Correct Answer: D

Rationale: A written nursing care plan fundamentally serves to facilitate the development of a nursing diagnosis. This procedure involves analyzing patient data and identifying health problems that nurses can address independently. This analysis then aids in determining the most appropriate nursing interventions for the identified health issues. Although evaluating the achievement of nursing care goals is an important aspect, it is not the primary function of a nursing care plan. Similarly, while delivering quality nursing care is crucial, it is a broader concept that includes many other facets beyond just the initial nursing diagnosis and interventions.