Nokea
When assessing a client's heart sounds, the nurse hears a scratching sound during both systole and diastole. These sounds become more distinct when the nurse has the client sit up and lean forward. The nurse should document the presence of a:
- A. Pericardial friction rub
- B. Heart murmur
- C. S3 heart sound
- D. S4 heart sound
Correct Answer: A
Rationale: A pericardial friction rub is characterized by a scratching sound that occurs during both systole and diastole. It becomes more distinct when the client is sitting up and leaning forward. This indicates an inflammation of the pericardial sac rubbing against the layers of the heart. Heart murmurs (choice B) are abnormal heart sounds caused by turbulent blood flow, not by friction like in a pericardial rub. S3 and S4 heart sounds (choices C and D) are additional heart sounds related to abnormal ventricular filling, not to pericardial friction rubs.
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When transferring a client to a long-term care facility, what information should the nurse include in the handoff report?
- A. Frequency of previous vital sign measurements
- B. Number of family members who have visited
- C. Time of the client's last bath
- D. Effectiveness of the last dose of pain medication
Correct Answer: D
Rationale: The correct answer is D: 'Effectiveness of the last dose of pain medication.' When transferring a client to a long-term care facility, it is crucial to provide information on the effectiveness of the last dose of pain medication to ensure continuity of care and appropriate pain management. This information helps the receiving facility understand the client's current pain status and plan future interventions accordingly. Choices A, B, and C are less relevant for the handoff report in this scenario. The frequency of previous vital sign measurements may be important, but the immediate effectiveness of pain medication takes precedence. The number of family members who have visited and the time of the client's last bath are not as critical for the receiving facility's immediate care planning compared to pain management details.
The healthcare provider is providing oral care to an unconscious patient and notes that the patient has extremely bad breath. Which term will the healthcare provider use when reporting to the oncoming shift?
- A. Cheilitis
- B. Halitosis
- C. Glossitis
- D. Dental caries
Correct Answer: B
Rationale: The correct term the healthcare provider will use when reporting the extremely bad breath of the unconscious patient to the oncoming shift is 'Halitosis' (Choice B). Halitosis specifically refers to bad breath. Cheilitis (Choice A) is inflammation of the lips, not related to bad breath. Glossitis (Choice C) is inflammation of the tongue, not directly associated with bad breath. Dental caries (Choice D) are cavities in the teeth, which can contribute to bad breath but are not the term used to describe bad breath itself.
A client with a history of falls is under the care of a nurse. Which of the following actions should be the nurse's priority?
- A. Complete a fall-risk assessment.
- B. Educate the client and family about fall risks.
- C. Eliminate safety hazards from the client's environment.
- D. Ensure the client uses assistive aids in their possession.
Correct Answer: C
Rationale: The nurse's priority should be to eliminate safety hazards from the client's environment as it directly reduces the risk of falls. Addressing environmental hazards is an immediate and crucial step in preventing falls. While completing a fall-risk assessment is important to understand the client's risk factors, educating the client and family about fall risks is essential for prevention, and ensuring the use of assistive aids is crucial for safety, eliminating safety hazards takes precedence as it directly mitigates the risk of falls.
A client is receiving 0.9% sodium chloride IV at 125 mL/hr. The nurse notes that the client has received only 80 mL over the last 2 hr. Which of the following actions should the nurse take first?
- A. Reposition the client
- B. Document the client's IV intake in the medical record
- C. Request a new IV fluid prescription
- D. Check the IV tubing for obstruction
Correct Answer: D
Rationale: The correct answer is to check the IV tubing for obstruction. The first step in the nursing process is assessment. By checking the IV tubing for obstruction, the nurse can assess and potentially correct any issues affecting the flow rate. This action may help to ensure that the prescribed infusion rate is maintained. Repositioning the client is not the priority at this stage as the issue seems related to the IV tubing. Documenting the intake or requesting a new prescription are not immediate actions needed to address the current situation with the IV fluid flow.
A healthcare professional is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the healthcare professional take?
- A. Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart.
- B. Recheck the pulse at the same site after 5 minutes.
- C. Measure the client's blood pressure.
- D. Record the irregularity and continue with other vital signs.
Correct Answer: A
Rationale: When an irregular pulse is detected, it is essential to count the apical pulse rate for a full minute to accurately determine the rhythm. This ensures a comprehensive assessment and helps in identifying any potential issues or abnormalities. Rechecking the pulse at the same site after 5 minutes (Choice B) may not provide an immediate understanding of the irregularity. Measuring the client's blood pressure (Choice C) is important but not directly related to addressing the irregular pulse. Recording the irregularity and continuing with other vital signs (Choice D) may overlook a potentially serious cardiac issue that requires immediate attention.