A nurse is listening to a school-age child's heart sounds and hears an abnormal noise after S2 that is heard best when the child is lying in the left lateral position. What action by the nurse is most appropriate?
A.
Arrange a cardiology consult.
B.
Document the findings in the chart.
C.
Notify the provider immediately.
D.
Perform assessments for fluid balance.
ANS: B
This sound is an S3 and is often heard in children and young adults. It is usually a benign finding but should be documented in the chart. A cardiology consult is not needed, nor does the nurse need to notify the provider immediately. Because this sound is not usually associated with heart disease, the nurse does not need to perform an assessment of fluid balance.
You might also like to view...
A client with a new burn injury asks the nurse why he is receiving intravenous cimetidine (Tagamet). What is the nurse's best response?
a. "Tagamet will stimulate intestinal move-ment so you can eat more." b. "Tagamet can help prevent hypovolemic shock, which can be fatal." c. "This will help prevent stomach ulcers, which are common after burns." d. "This drug will help prevent kidney dam-age caused by dehydration."
The client is receiving an antithyroid medication to treat hyperthyroidism. Which of the following should be included in client education regarding the initiation of this therapy?
A. "Increased need for sleepy or not tolerating cold like you used to can occur when taking this medication. If it does, notify your physician." B. "Nausea and vomiting are serious complication of the medication you are taking." C. "Take your pulse every day, as you were taught. If it is too fast, call your doctor." D. "This medication may cause dyspnea or vertigo. Notify your health care provider if this occurs."
Changes in the urinary system with aging include which of the following?
a. Kidneys atrophy. b. Bladder size increases. c. Bladder muscles strengthen. d. Blood flow to the kidneys increases.
Which of the following reimburses according to the cost of treatment of specific diagnosis-related groups (DRGs)?
a. Health promotion programs b. Managed care systems c. Prospective reimbursement system d. Health maintenance organizations