A patient tells the nurse that the cardiologist has told her that she will likely need a mitral valve replacement in a few years. The nurse can best hear her mitral valve
1. Over the apex of the left ventricle.
2. At the second intercostal space to the right of the sternum.
3. At the second intercostal space to the left of the sternum.
4. At the fourth intercostal space just to the left of the sternum.
ANS: 1
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A new nurse is caring for a child after spinal fusion to correct scoliosis. Which action by the new nurse causes the experienced nurse to intervene?
A. Assesses neurological status and vital signs every hour B. Instructs patient to turn by pulling on side rails C. Monitors chest tube for air leakage and drainage D. Promotes use of the incentive spirometer each hour
The nurse is talking with the patient when the monitor alarms and shows a wavy baseline without a PQRST complex. The nurse should:
a. defibrillate the patient immediately. b. initiate basic life support. c. initiate advanced life support. d. assess the patient and the electrical leads.
The nurse is caring for a 4-year-old child with cerebral palsy (CP). The child, developmentally, is at an infant stage. Appropriate developmental stimulation for this child should be what?
a. Playing "pat-a-cake" with the child b. None so the child does not become overstimulated c. Putting a colorful mobile with music on the bed d. Giving the child a coloring book and crayons
A client is ordered to receive cyclophosphamide (Cytoxan). The client is advised to drink increased water and fluids to:
a. prevent renal failure. b. prevent liver dysfunction. c. prevent hemorrhagic cystitis. d. increase the red blood cell count.