The nurse preparing to auscultate the apical heart rate on the client having an annual physical examination would do what first?
1. Document client response.
2. Remove the cover sheet from the client.
3. Warm the bell of the stethoscope.
4. Observe respiratory effort.
3
Rationale: The nurse would use the bell of the stethoscope, warmed in the hand for client comfort. The drape need only be removed enough to bare the apical area of the chest. Respiratory effort would be performed when assessing respiratory rate, and documentation would be done after auscultating heart rate.
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Which of the following statements is TRUE regarding the performance of alternative or complementary therapies by nurses?
a. Experimental alternative therapies cannot be performed on a client without meeting study requirements. b. Nurses can perform any type of alternative therapy upon receipt of initial licensure. c. Some types of alternative therapies are not within the scope of practice for nurses. d. State law requires nurses to meet certain educational standards before performing any alternative therapy.
A health care provider has ordered an MRI (magnetic resonance imaging) of the liver. The nurse's first action is to
a. prepare the patient psychologically and physically for the procedure. b. monitor the patient's response to the procedure. c. assess the patient after the procedure. d. inform the patient's family of the results.
Which symptom of Parkinson's disease has the highest priority for nursing intervention?
a. Tremor b. Akathisia c. Dysphagia d. Tardive dyskinesia
The nurse is creating a teaching plan for a client recovering from total hip replacement surgery. What should the nurse include in this client's plan?
1. The content to be included 2. The outcome for the teaching 3. The approaches used to teach the content 4. The evaluation of the effectiveness of teaching 5. The amount of time needed to cover the content