While performing a focused cardiac assessment, the nurse auscultates an abnormal swooshing sound. Which action is most appropriate to clarify the nurse's finding?
a. The nurse uses the diaphragm of the ste-thoscope while asking the patient to take a deep breath.
b. The nurse uses the bell of the stethoscope while asking the patient to lean forward.
c. The nurse asks the patient about a history of heart stents.
d. The nurse asks the patient about a history of cardiac dysrhythmias.
B
Heart murmurs usually generate a swooshing sound that results from turbulent blood flow (usually through damaged valves). The nurse should use the bell of the stethoscope and place it lightly on the skin. Leaning the patient forward may amplify or clarify the sound. Asking the pa-tient about heart stents and abnormal heart rhythms does not clarify the presence or history of a heart murmur.
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The nurse clarifies the concept of "mental health" by defining it as:
a. a wellness of attitude. b. a person's response to disease and dysfunction. c. the ability to cope and adjust to everyday stresses. d. how the person performs activities of daily living.
A 4-month-old infant comes to the clinic for a well-infant checkup. Immunizations she should receive are DTaP (diphtheria, tetanus, acellular pertussis) and IPV (inactivated poliovirus vaccine). She is recovering from a cold but is otherwise healthy and a
a. DTaP and IPV can be safely given. b. DTaP and IPV are contraindicated because she has a cold. c. IPV is contraindicated because her sister is immunocompromised. d. DTaP and IPV are contraindicated because her sister is immunocompromised.
The adult client is incontinent and wears incontinence briefs when using the wheelchair. An irritated rash has developed in the perianal area. What care should the nurse provide?
1. Wash the area with soap and hot water at every brief change. 2. Apply a petroleum-based cream to the area after cleaning. 3. Wipe the skin with an alcohol-free barrier film agent after cleaning. 4. Keep the client in bed on absorbent pads until the area clears.
Because dissemination from individuals in clinical practice is essential to building nursing knowledge, unit-based ____________ offer nurses the opportunity to share their unique knowledge in a visually interesting and concise format
a. posters b. debates c. classes d. publications