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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 the
diaphragm of the stethoscope positioned at the left sternal border.
Which of the following heart sounds should the nurse document?
A. Audible Click
B. Murmur
C. Third heart sound
D. Pericardial friction rub
A nurse is obtaining the blood pressure in a client's lower extremity.
Which of the following action should the nurse take?
A. Auscultate forthe blood presure at the dorsalis pedis artery.
B. Measure the blood pressure with the client sitting on the side of the bed.
C. Place the cuff 7.6cm (3in) above the popliteal artery.
D) place the bladder of the cuff over the posterior aspect of the thigh
A charge nurse is teaching adult cardiopulmonary resusciation (CPR) to a group of newly
licensed nurses. Which of the following actions should the charge nurse teach as the first
response in CPR?
A. Call for assisstance
B. Begin Chest compressions
C. Confirm unresponsiveness.
D. Give rescue breaths.
C) 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?
A. Explain the x-ray procedure to the client.
B. Help the client into a wheelchair before the transporter arrives.
C. Ask if the client has any questions.
D) Identify the client using to identifiers
A nurse is caring for a child who is postoperative following a tonsillectomy.
Which of the following actions should the nurse take?
A. Encourage the child to cough frequently to clear congestion from anesthesia.
B. Place a heating pad at the child's neck for comfort.
C. Administer analgesics to the child on a routine schedule throughout the day and night.
D. Provide the child with ice cream when oral intake is initiated.
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