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 for the 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. 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? A. The involvement of the client in planning the change. B. The emphasis the provider places on the dietary changes. C. The learning theory the nurse uses to teach the dietary changes. D. The extent of the dietary changes planned for the client. 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? A. Obtaining hydrogen peroxide for the trachesotomy care. B. Obtainging cotton balls for the tracheostomy care. C. Obtaining sterile glovesfor the tracheostomy care. D. Obtaining a sterile brush 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? A. Place the client supine. B. Keep both side rails up. C. Raise the level of the bed. D. Inspect the client's mouth using a finger sweep. 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? A. The client fully understands the provider's explannation of the procedure. B. The client has been informed about the risks and benefits of the procedure. C. The nurse witnessed the provider's explanantion of the procedure. D. The signature on the preoperative consent form is the client's. A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first? A. Open all sterile supplies and solutions. B. Stabilize the tracheostomy tube. C. Don sterile gloves D. Perform hand hygiene A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse .make? A. It's for your safety. Dentures can slip and block your airway during surgery. B. You wouldn't want your teeth to be lost or broken during surgery, would you? C. The anesthesiologist requires everyone to remove their dentures. D. What worries you about being without your teeth?