The nurse completes auscultation of the heart on an older adult client. Which finding is considered normal for this client?

Murmurs.

Absent sounds.

No adventious sounds.

Adventious sounds.

Answer and Explanation

The Correct Answer is A

A. Murmurs can be a normal finding in older adults due to age-related changes in the heart valves or blood flow. They are not necessarily indicative of pathology if they are not associated with symptoms or changes in the client's condition.

B. Absent heart sounds would be abnormal and could indicate severe underlying issues such as cardiac arrest or severe hypovolemia.

C. While no adventitious sounds are generally expected, the presence of murmurs is considered normal in this age group.

D. Adventitious sounds (such as crackles or wheezes) are not normal in heart auscultation and would suggest potential pathologies.

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Correct Answer is ["C","D","B","A"]

Explanation

The unit manager should first note the date and time of the behavior to have a record of the incident. This information is crucial for any follow-up actions and for maintaining accurate documentation. Next, the manager should discuss the issue privately with the UAP to understand the reasons behind their actions and to communicate the importance of following unit protocols. After this discussion, planning for scheduled break times can be implemented, which may prevent future occurrences by providing clear expectations and structure. Lastly, the manager should evaluate the UAP for signs of improvement following these interventions to ensure that the behavior has been corrected and to determine if further action is needed.

A. Twin siblings admitted with scarlet fever that is complicated with pneumonia. B. An older client with scabies who is admitted from an extended care facility. C. A female adolescent admitted with multiple genital Herpes simplex II lesions. D. A client with a positive Mantoux and sputum cultures results positive for acid-fast bacillus (AFB).

Correct Answer is D

Explanation

A. Scarlet fever and pneumonia do not require airborne precautions; they are primarily spread through respiratory droplets.

B. Scabies is a skin infestation that requires contact precautions, not airborne precautions.

C. Herpes simplex II lesions require contact precautions and are not airborne.

D. A positive Mantoux test and sputum cultures positive for acid-fast bacillus indicate tuberculosis, which requires airborne precautions, including a negative airflow room and the use of a particulate respirator mask.

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The nurse completes auscultation of the heart on an older adult client. Which finding is considered normal for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An unlicensed assistive personnel (UAP) leaves the unit without notifying the staff. In which order should the unit manager implement these interventions to address the UAP's behavior? (Place the actions in order from first on top to last on bottom.)

Correct Answer is ["C","D","B","A"]

Explanation

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

Correct Answer is D

Explanation

The nurse is providing dietary education to a client in end stage kidney failure who requires dialysis three times a week. Which information is important for the nurse to include about the client's daily diet?

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During an admission assessment, a client reports currently using heroin. Which information is most important for the nurse to consider in the plan of care?

An older client with osteoarthritis reports increasing pain and stiffness in the right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of the symptoms?

Patient Data Exhibits The nurse reviews the findings in the history and physical. Drag from Word Choices to complete the sentence. The nurse recognizes that dropdown, dropdown, and dropdownare findings consistent with elder mistreatment.