In doing a breath sound assessment on a client who has left ventricular failure, the nurse would anticipates the finding of
a. audible S3 and S4.
b. crackles in the lung bases.
c. inspiratory wheeze.
d. pericardial friction rub.
B
Crackles frequently signal left ventricular failure and usually occur just after the onset of an S3 gallop. As pulmonary capillary pressure rises from the backward pressure of left ventricular fail-ure, fluid shifts into the intra-alveolar spaces, and crackles can be auscultated.
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The nurse is preparing to obtain a rectal temperature. Nursing care is correct if the nurse inserts the thermometer how far into the rectum of an adult?
a. 1.3 cm (1/2 inch) b. 3.5 cm (1 1/2 inches) c. 5.1 cm (2 inches) d. 6.4 cm (1 1/2 inches)
What disorder of the testes is most likely the diagnosis?
A 29-year-old married computer programmer comes to your clinic, complaining of “something strange” going on in his scrotum. Last month while he was doing his testicular self-examination he felt a lump in his left testis. He waited a month and felt the area again, but the lump was still there. He has had some aching in his left testis but denies any pain with urination or sexual intercourse. He denies any fever, malaise, or night sweats. His past medical history consists of groin surgery when he was a baby and a tonsillectomy as a teenager. He eats a healthy diet and works out at the gym five times a week. He denies any tobacco or illegal drugs and drinks alcohol occasionally. His parents are both healthy. On examination you see a muscular, healthy, young-appearing man with unremarkable vital signs. On visualization the penis is circumcised with no lesions; there is a scar in his right inguinal region. There is no lymphadenopathy. Palpation of his scrotum is unremarkable on the right but indicates a large mass on the left. Placing a finger through the inguinal ring on the right, you have the patient bear down. Nothing is felt. You attempt to place your finger through the left inguinal ring but cannot get above the mass. On rectal examination his prostate is unremarkable. A) Hydrocele B) Scrotal hernia C) Scrotal edema D) Varicocele
According to the American Nurses Association (ANA) Standards of Practice, the psychiatric mental health nurse focuses on the:
a. diagnosis of psychiatric disorders b. diagnosis of human responses to mental problems c. treatment of client social welfare problems d. treatment of biochemical disorders
The nurse is reviewing arterial blood gas results of a pt with acute glomerulonephritis. the pH of the sample is 7.35. As acidosis is likely to be present because of the hydrogen ion retention and loss of bicarbonate, how does the nurse interpret this data?
a. normal pH with respiratory compensation b. acidosis with failure of respiratory compensation c. alkalosis with failure of respiratory compensation d. normal pH with metabolic compensation