The nurse notes an S3 heart sound while performing an assessment on a patient admitted with an acute myocardial infarction. The nurse notifies the physician of the finding, which most likely suggests:
a. Heart failure
b. Coronary artery disease
c. Hypertension
d. Pulmonic stenosis
A
A third heart sound, commonly referred to as S3, is heard with heart failure or volume overload. S4 heart sound may be auscultated with coronary artery disease, hypertension, and pulmonic stenosis.
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Which of the following best describes how people with mental illness are viewed by the general public?
a. Individuals in need of assistance b. Criminals who need to be institutionalized c. Lazy, weak, and immoral d. Contributing members of society
The nurse is assessing a patient with a new arteriovenous fistula, but does not hear a bruit or feel a thrill. Pulses distal to the fistula are not palpable. The nurse should:
a. reassess the patient in an hour. b. raise the arm above the level of the patient's heart. c. notify the provider immediately. d. apply warm packs to the fistula site and reassess.
The nurse has implemented a bladder retraining program for an older adult patient. The nurse places the patient on a timed voiding schedule and performs an ultrasonic bladder scan after each void
The nurse notes that the patient typically has approximately 50 mL of urine remaining in her bladder after voiding. What would be the nurse's best response to this finding? A) Perform a straight catheterization on this patient. B) Avoid further interventions at this time, as this is an acceptable finding. C) Place an indwelling urinary catheter. D) Press on the patient's bladder in an attempt to encourage complete emptying.
During assessment of the client with pneumonia, the nurse notes a bluish coloration of the skin. The nurse interprets this to mean the client is:
1. in the early stages of a respiratory problem. 2. improving. 3. hypoxic. 4. hyperventilating.