A nurse is reviewing a client's history and notes that the client has aortic stenosis. What heart sound would the nurse expect to hear?
a. Rubbing
b. S4 heart sound
c. Gallop
d. Swooshing
d. Swooshing
rationale: Swooshing sounds indicate murmurs, which are evidence of valvular disease (stenosis or regurgitation). An aortic murmur would best be auscultated either over the 2nd intercostal space, right sternal border, or at Erb's point (3rd intercostal space, left sternal border.) Rubbing indicates the presence of inflammation in the pericardium, such as in pericarditis. An S4 sound is caused by the atria forcefully contracting to try to overcome an abnormally stiff or hypertrophic ventricle. If a gallop sound (S3) is heard, this indicates blood prematurely rushing into the ventricle. This is often related to volume overload as seen in heart failure, but could also be caused by pulmonary hypertension or coronary artery disease.
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1. Focus exclusively on the reported illness. 2. Review health promotion and maintenance activities. 3. Ask the mother to leave the room after obtaining the history. 4. Obtain a comprehensive history, including sociodemographic data.
The mother of a toddler asks the nurse: "Now that my child has outgrown his infant car seat, what should I do when we are in the car?" Which is the best response by the nurse?
1. "Place him in a booster chair on the seat beside you so you can watch him." 2. "Be sure to select a car seat according to his weight and height, and make sure it contains shoulder harnesses." 3. "Your child should remain in the rear-facing car seat until he reaches 40 pounds." 4. "The child can now be buckled safely into the regular car seat belts."
The nurse is conducting a class for a group of pregnant clients. Which topic should the nurse include with regard to safety of the fetus?
A) Pedestrian accidents B) Suffocation in the crib C) Alcohol consumption D) Drowning
What is the most important precaution to take when administering rasburicase?
a. Wearing gloves to prevent absorption of the drug through skin and mucous membranes b. Placing the patient in an upright position for 30 minutes after the drug is administered c. Keeping the emergency equipment in the room during administration of the drug d. Ensuring that the patient drinks at least 16 ounces of fluid with each dose