Which of the following assessment findings would indicate fluid volume excess?
a. Venous filling of the hand veins greater than 5 seconds
b. Distended neck veins in the supine position
c. Presence of orthostatic hypotension
d. Third heart sound
D
Auscultation of the heart requires not only assessing rate and rhythm but also listening for extra sounds. Fluid overload is often accompanied by a third or fourth heart sound, which is best heard with the bell of the stethoscope.
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Which of the following variables is not a component of the Gail Model?
A. Age at menarche B. Number of breast biopsies C. Age at first live birth D. Number of live births
A client who experienced a spinal cord injury 1 hour ago is brought to the emergency depart-ment. Which prescribed medication does the nurse prepare to administer to this client?
a. Intrathecal baclofen (Lioresal) b. Methylprednisolone (Medrol) c. Atropine sulfate d. Epinephrine (Adrenalin)
Transitory tachypnea of the newborn (TTN) is thought to occur as a result of:
a. a lack of surfactant. b. hypoinflation of the lungs. c. delayed absorption of fetal lung fluid. d. a slow vaginal birth associated with meconium-stained fluid.
The nurse is preparing to begin the patient hand-off procedure for five patients. Who should the nurse include in this process?
a. Only the licensed nurses b. The unit health care personnel c. The entire interdisciplinary team d. The nurses and healthcare provider