The nurse is auscultating heart tones on an older client and hears the following sound. What is the nurse's best action? (Click the media button to hear the audio clip.)
a. Administer a diuretic.
b. Document the finding.
c. Decrease the IV flow rate.
d. Evaluate the medications.
B
The sound heard is an atrial gallop S4 . An atrial gallop may be heard in older clients because of a stiffened ventricle. The nurse should document the finding, but no other intervention is needed at this time.
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One example of a research-based classification system of nursing actions is the Omaha System
A) True B) False
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The nurse is preparing to administer an antibiotic to a client. The nurse understands that the use of the antibiotic is:
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