How does the nurse detect an extra heart sound in an adult?
a. Using the bell of a stethoscope
b. With a pulse oximeter
c. Using the diaphragm of a stethoscope
d. With a Doppler ultrasound probe
ANS: A
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While assessing a client on a cardiac unit, a nurse identifies the presence of an S3 gallop. Which action should the nurse take next?
a. Assess for symptoms of left-sided heart failure. b. Document this as a normal finding. c. Call the health care provider immediately. d. Transfer the client to the intensive care unit.
A nurse is emptying an orthopedic surgery patient's closed suction drainage at the end of a shift. The nurse notes that the volume is within expected parameters but that the drainage has a foul odor. What is the nurse's best action?
A) Aspirate a small amount of drainage for culturing. B) Advance the drain 1 to 1.5 cm. C) Irrigate the drain with normal saline. D) Inform the surgeon of this finding.
Which patient on a geriatric medicine unit would the nurse recognize as being most prone to sleep problems?
A) An obese female patient receiving IV antibiotics for the treatment of a urinary tract infection B) A 74-year-old female receiving transfusions of packed red blood cells for an upper GI bleed C) A 78-year-old male recovering from an ischemic stroke and has skin breakdown on the coccyx D) A male patient admitted for exacerbation of chronic obstructive pulmonary disease (COPD) with a history of angina
The nurse is conducting a health history as part of a spiritual assessment. Which topics will the nurse collect during the psychosocial profile portion of this assessment? Select all that apply
1) Basic religious information 2) Marital status 3) Contact person 4) Dietary preferences 5) Typical daily activities