A nurse has applied a blood pressure cuff to a client's upper arm, positioned the stethoscope over the client's brachial artery, inflated the cuff and is now slowly releasing air from the cuff
The nurse should recognize the client's peak blood pressure when what sound is audible? A) A whooshing sound that quickly intensifies
B) A clicking sound that appears suddenly
C) The "lub dub" of the client's heart rate
D) A faint, clear tapping sound
D
Feedback:
Korotkoff sounds have five unique phases. Phase I begins with the first faint but clear tapping sound that follows a period of silence as pressure is released from the cuff. When the first sound occurs, it corresponds to the peak pressure in the arterial system during heart contraction, or the systolic pressure measurement. This sound does not have the two-stage sound of a heartbeat.
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The nurse discontinues a client's Foley catheter following diagnostic procedure. When assessing the client's voided urine, it is noted to be concentrated with red strings. Which nursing action is best?
A) Ambulate the client in the hall. B) Instruct the client to increase fluid intake. C) Call the physician for further instructions. D) Wait to see the next voided specimen.
The nurse receives an order to administer 8 units regular insulin and 20 units NPH insulin before breakfast. Using a U-100 syringe, the nurse would prepare this dose by:
1. drawing up 8 units NPH, then 20 units regular in the same syringe. 2. drawing up 8 units regular in one syringe, and 20 units NPH in a separate syringe. 3. drawing up 8 units regular, then 20 units NPH in the same syringe. 4. giving the 20 units NPH insulin 15 minutes before food, and the 8 units regular when the food arrives.
A tuft of capillaries in the kidney that is responsible for filtering the blood is called the:
a. Bowman's capsule c. afferent arteriole b. Loop of henle d. glomerulus
Which of the following outcomes, made by a nurse planning care for a client recently fitted with a hearing aid, best reflects an understanding of short-term client education goals?
1. Client will properly clean the hearing aid ear piece daily with soap and water. 2. Client will state 3 positive effects of wearing his hearing aid at follow-up ap-pointment. 3. Client will wear hearing aid while awake to help improve his ability to understand instructions. 4. Client will demonstrate ability to change the batteries in his hearing aid before leaving clinic today.