During a cardiovascular assessment of a healthy adult, of the findings listed below, those labeled with numbers ____________________ are normal. (Your answer should appear as numbers separated by commas and spaces [e.g., 1, 2, 3, 4].)
1. Heart rate of 102 beats per minute
2. S1 and S2 present with regular rhythm
3. Capillary refill greater than 3 seconds
4. Blood pressure of 124/86
5. Warm, elastic turgor
6. Pulse of smooth contour with 2+ amplitude
ANS:
2, 5, 6
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A child is admitted to the hospital unit with physical injuries. The nurse is taking the child's history. The statement by the parent that would be most suspicious for abuse is:
1. "I did not realize that my baby was able to roll over yet, and I was just gone a minute to check on dinner when the baby rolled off of the couch and onto our tile floor." 2. "The baby's 18-month-old brother was trying to pull the baby out of the crib and dropped the baby on the floor." 3. "I placed the baby in the infant swing. His 6-year-old brother was running through the house and tripped over the swing, causing it to fall." 4. "I was walking up the steps and slipped on the ice, falling while carrying my baby."
On a hot humid day, an emergency department nurse is caring for a client who is confused and has these vital signs: temperature 104.1 ° F (40.1 ° C), pulse 132 beats/min, respirations 26 breaths/min, blood pressure 106/66 mm Hg. Which action should the nurs
a. Encourage the client to drink cool water or sports drinks. b. Start an intravenous line and infuse 0.9% saline solution. c. Administer acetaminophen (Tylenol) 650 mg orally. d. Encourage rest and re-assess in 15 minutes.
When discussing family tasks with a client, the nurse identifies integrating new family members as a task of which family stage?
1. Early childbearing 2. Families with preschool children 3. Families with teenagers 4. Families of middle years
What temperature should ear drops be when applying them?
a. Just above freezing ?33 ?F b. Warmed to 104 ?F c. Refrigerated to 40 ?F d. Room temperature