Ordered: Hydroxyzine (Vistaril) 35 mg IM stat

Available: Hydroxyzine (Vistaril) 50 mg/mL

Administer: ____ ml

A. Lub-dub sounds:

This describes the normal heart sounds, with the "lub" representing the closing of the mitral and tricuspid valves (S1) and the "dub" representing the closing of the aortic and pulmonic valves (S2). This is the typical and expected sound of a healthy heart.

B. Gentle blowing or swooshing noise:

This describes the characteristic sound of a heart murmur. Murmurs are abnormal sounds caused by turbulent blood flow, and they are often described as a gentle blowing or swooshing noise heard between the normal heart sounds.

C. Scratchy, leathery heart noise:

This description is not typical for heart sounds or murmurs. Heart sounds are usually described in terms of tones, clicks, or swooshing rather than scratchy or leathery.

D. Abrupt, high-pitched snapping noise:

This description is not typical for heart sounds or murmurs. Heart murmurs are generally characterized by a more continuous, blowing, or swooshing quality, rather than abrupt, high-pitched snapping noises.

A. Mutually establish desired outcomes of the plan of care:

While establishing desired outcomes is an important part of the nursing process, nursing diagnoses themselves do not necessarily focus on mutually establishing these outcomes. Nursing diagnoses help identify health problems and needs, which then guide the development of outcomes during the planning phase.

B. Guide selection of nursing interventions to meet expected outcomes:

This is the correct answer. Nursing diagnoses help determine the specific needs and problems a patient is facing. Once identified, nursing interventions can be chosen to address these needs and work towards achieving expected outcomes.

C. Establish a database of information for future comparison:

Establishing a database of information is more related to the assessment phase of the nursing process. Nursing diagnoses are formulated based on the analysis of the collected data and serve to guide subsequent steps in the nursing process, particularly planning and intervention.

D. Evaluate the effectiveness of the established plan of care:

Evaluating the effectiveness of the established plan of care is part of the later stages of the nursing process. Nursing diagnoses help in planning and implementing interventions, and evaluating their effectiveness comes after these interventions have been carried out.