A nurse auscultates low-pitched, coarse snoring sounds in a patient's lungs during inhalation. What is the most appropriate action for the nurse to take at this time?
a. Palpate the posterior thorax for vocal fremitus.
b. Ask the patient to cough and repeat auscultation.
c. Auscultate the posterior thorax for vocal sounds.
d. Percuss the posterior thorax for tone.
ANS: B
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An older adult client is diagnosed with a left cerebral hemorrhage. To meet the needs of the client and family, the nurse will provide teaching in which areas?
Select all that apply. A) Time adjustment to complete activities B) How to use a sign board C) Nutrition support D) Transfer techniques E) Information about impulse control
The older adult patient in a long-term care facility is at risk for injury because of confusion. The patient's gait is stable. To prevent injury to the patient, the best method of restraint if prescribed would be:
1. a geriatric chair. 2. an alarm bracelet. 3. a vest restraint. 4. wrist and ankle restraints.
One nursing theorist included the assumption, that caring and love are universal and mysterious forces, in addition to other assumptions in her theory. In which theory is this an assumption?
A) Philosophy and Science of Caring B) Adaptation Model C) Intersystem Model D) Modeling and Role-Modeling
The nurse administers IV morphine to a 4-year-old postoperative client. Which assessment finding requires further evaluation by the nurse?
1. Pulse decreased from 136 to 104 2. Blood pressure dropped from 110/72 to 90/55 3. Respiratory rate went from 42 to 16 4. Child pulls away from nurse who wants to assess surgical site