Review of the medical record reveals that a patient has a summation gallop. Which pattern of heart sounds would the nurse expect?
1. S1 followed closely by S2
2. S1 followed closely by S2 followed closely by S3
3. S1 followed closely by a split S2
4. S4 followed by S1 followed by S2 followed by S3 followed by S4
Answer: 4
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The nurse is caring for a patient who will be using a hydromorphone (Dilaudid) PCA analgesia pump following surgery. Which intervention is the highest priority for the nurse to include in the patient's care plan for the diagnosis:
Readiness for enhanced knowledge r/t appropriate management of PCA pump? a. Assess the patient's respiratory status every 30 minutes after PCA pump started. b. Review patient's medication profile to check for interactions with hydromorphone. c. Teach the patient how to use PCA pump when awake and aware and pain level is tolerable. d. Keep naloxone (Narcan) available at the bedside in case of respiratory suppression.
The nurse is caring for a patient who recently suffered a cerebrovascular accident (CVA). The family asks the nurse why their father had a seizure. What is the best response by the nurse?
a. "The seizure was most likely caused by brain cells being deprived of oxygen due to a blood clot in the brain." b. "The stroke generated a toxin that excites the brain cells." c. "The stroke causes an alteration in the cells adjacent to the blood clot." d. "The stroke causes an increase in the de-polarization of the brain cells due to the clot formation."
To palpate the liver during a head-to-toe physical assessment, the nurse
a. places one hand on the patient's back and presses upward and inward with the other hand below the patient's right costal margin. b. places one hand on top of the other and uses the upper fingers to apply pressure and the bottom fingers to feel for the liver edge. c. presses slowly and firmly over the right costal margin with one hand and withdraws the fingers quickly after the liver edge is felt. d. places one hand under the patient's lower ribs and presses the left lower rib cage forward, palpating below the costal margin with the other hand.
A patient with type 1 diabetes who takes insulin reports taking propranolol for hypertension. The nurse is concerned because
a. the beta blocker can cause insulin resistance. b. using the two agents together increases the risk of ketoacidosis. c. propranolol increases insulin requirements because of receptor blocking. d. the beta blocker can mask the symptoms of hypoglycemia.