While assessing a seven-year-old girl, the nurse notices a regular—irregular heartbeat. The nurse listens carefully and notes that the heart rate increases on inspiration and decreases on expiration
What is the most appropriate action for the nurse to take next? 1. Record the finding as normal.
2. Notify the physician.
3. Schedule an EKG.
4. Ask the mother if a murmur has been detected before.
1
Rationale 1: This is sinus arrhythmia and is a normal finding in children but not in adults.
Rationale 2: This is a normal finding. It should be recorded, not reported.
Rationale 3: Nurses do not order tests, including EKGs.
Rationale 4: There is no evidence of a murmur in the stem. This is a normal finding.
Global Rationale:
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Which part of planning should the nurse indicate is the family's priority? a. Sharing household responsibilities b. Preparing the house for her arrival c. Helping her use her skills and talents d. Setting limits on nighttime activities
The patient is admitted with constipation. In anticipation of treatment, the nurse prepares to:
a. give medications that will suppress the autonomic nervous system. b. provide therapies that will innervate the autonomic nervous system. c. teach the patient that the submucosa is the innermost part of the gut wall. d. give medications intravenously since the submucosa has no blood vessels.
Which of the following authorized the development of a national, near real-time information network to coordinate federal and state response to public health emergencies?
1. Health Insurance Portability and Accountability Act 2. Pandemic and All-Hazards Preparedness Act 3. Sarbanes-Oxley Act 4. Federal Information Privacy and Security Act
A patient is taking trimethoprim (Primsol) 200 mg orally once a day. For which adverse effect will you monitor?
a. GI bleeding b. Kidney failure c. Anaphylaxis d. Angioedema