Nokea
A nurse auscultated heart tones on an older adult client. Which action should the nurse take based on the heart tones heard?
- A. Administer a diuretic.
- B. Document the finding.
- C. Decrease the IV flow rate.
- D. Evaluate the client’s medications.
Correct Answer: B
Rationale: Documenting the findings is the appropriate action unless the heart tones indicate an abnormality requiring intervention.
You may also like to solve these questions
What are THREE associated echo findings for an infant with wide spaced nipples and a webbed neck?
- A. LV systolic dysfunction
- B. Blunted abdominal aortic Doppler
- C. Bicuspid aortic valve
- D. All of the above
Correct Answer: D
Rationale: These are common echo findings that can be associated with congenital syndromes affecting the heart.
The following procedures may abort an attack of SVT EXCEPT
- A. placing of the face in ice water
- B. straining
- C. breath holding
- D. standing on head
Correct Answer: D
Rationale: Standing on the head is not a practical or effective method to terminate SVT.
Features that would increase suspicion of cerebral palsy at age 9 months include:
- A. Presence of Moro reflex
- B. Abductor spasm
- C. Hand dominance
- D. Grasp reflex
Correct Answer: C
Rationale: Hand dominance at 9 months is a red flag for cerebral palsy. The persistence of primitive reflexes like the Moro and grasp reflexes can also be indicative.
Skin lesions characteristically associated with CNS problems:
- A. Dermatitis herpetiformis
- B. Vitiligo
- C. Strawberry angioma on face
- D. Axillary freckling
Correct Answer: D
Rationale: Axillary freckling
Acute bronchiolitis is associated with:
- A. A higher incidence in infants than in school children
- B. The production of copious amounts of purulent sputum
- C. Widespread fine crackles
- D. A polymorphonuclear leucocytosis
Correct Answer: A
Rationale: Acute bronchiolitis is more common in infants and is associated with fine crackles. Purulent sputum and polymorphonuclear leucocytosis are not typical features.