In auscultating the client's breath sounds, you hear harsh, hollow sounds over the trachea. What is your best action?
A. Listen again with the bell of the stethoscope rather than the diaphragm.
B. Ask the client to cough and spit out any collected mucus.
C. Document the finding as the only action.
D. Notify the physician.
C
The normal and expected breath sounds auscultated over the trachea are tubular or bronchial, which are harsh, hollow, and blowing.
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The nurse making the schedule for the daily dose of furosemide (Lasix) would schedule the administration for which of the following times?
a. Late in the afternoon b. At bedtime c. With any meal d. In the morning
A client tells the nurse that his sexual functioning is normal when his wife wears short red
nightgowns. He states, "Without the red nighties, I am not interested in sex.". The nurse can assess this as consistent with a. pedophilia. b. exhibitionism. c. fetishism. d. voyeurism.
During the physical examination of a client, the nurse checks the client for neck vein distention. To perform this assessment properly, the client should be positioned
a. first lying, then sitting, then standing. b. in a side-lying position with knees flexed. c. lying supine with head of bed elevated 15-30 degrees. d. sitting upright with neck flexed slightly forward.
The nurse provides care in a hospital in an inner-city with a large immigrant population. How can the nurse provide the most culturally competent care?
1. Approach the care of every patient in the same manner. 2. Plan to attend educational programs to understand ethnic differences in health values. 3. Discuss with the supervisor the types of patients for whom the nurse feels prepared to provide care. 4. Realize that the best care is standardized care.