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A nurse is assessing the heart sounds of a client who has developed chest pain that becomes
worse with inspiration. the nurse auscultates a high-pitched scratching sound during both
systole and diastole with diaphragm of the stethoscope positioned at the left sternal border.
Which of the following heart sounds should the nurse document?
Pericardial friction rub
A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following
actions should the nurse take?
Place the bladder of the cuff over the posterior aspect of the thigh
A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly
licensed nurses. Which of the following actions should the charge nurse teach as the first
response in CPR?
Confirm unresponsiveness
A nurse is caring for a client who requires a chest x-ray. Prior to the client being
transported for the procedure, which of the following actions should the nurse take first?
Identify the client using two identifiers
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the
following actions should the nurse take?
Administer analgesics to the child on a routine schedule throughout the day and night.
A nurse is providing teaching to a client who has heart failure about how to reduce his
daily intake of sodium. Which of the following factors is the most important in determining
the client's ability to learn new dietary habits?
The involvement of the client in planning the change
A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client.
Which of the following actions by the newly licensed nurse requires intervention?
Obtaining cotton balls for the tracheostomy care
A nurse is preparing to perform mouth care for an unresponsive client. Which of the
following actions should the nurse plan to take?
Raise the level of the bed
A nurse is witnessing a client sign an informed consent form for surgery. Which of the
following describes what the nurse is affirming by this action?
The signature on the preoperative consent form is the client's
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