A nurse auscultated heart tones on an older adult client. Which ...

[joblessjake]

A nurse auscultated heart tones on an older adult client. Which action should the nurse take based on heart tones heard? (Click the media button to hear the audio clip.)
 
  a. Administer a diuretic.
  b. Document the finding.
  c. Decrease the IV flow rate.
  d. Evaluate the client's medications.

Question 2

A nurse prepares a client for coronary artery bypass graft surgery. The client states, I am afraid I might die. How should the nurse respond?
 
  a. This is a routine surgery and the risk of death is very low.
  b. Would you like to speak with a chaplain prior to surgery?
  c. Tell me more about your concerns about the surgery.
  d. What support systems do you have to assist you?

[amy.lauersdorf90]

Answer to Question 1

ANS: B
The sound heard is an atrial gallop S4. An atrial gallop may be heard in older clients because of a stiffened ventricle. The nurse should document the finding, but no other intervention is needed at this time.

Answer to Question 2

ANS: C
The nurse should discuss the client's feelings and concerns related to the surgery. The nurse should not provide false hope or push the client's concerns off on the chaplain. The nurse should address support systems after addressing the client's current issue.