A client tells the nurse that he is concerned because his provider told him he has a heart murmur. The nurse should explain to the client that a murmur

indicates turbulent blood flow through a valve.

is an extra sound due to blood entering an inflexible chamber.

is a high-pitched sound due to a narrow valve.

means that there is some inflammation around the heart.

Answer and Explanation

The Correct Answer is A

A. A heart murmur typically indicates turbulent blood flow through a heart valve. This turbulence can occur due to various reasons, such as valve stenosis (narrowing), regurgitation (leakage), or structural abnormalities of the valves. The turbulent flow produces audible sounds that can be heard with a stethoscope during cardiac auscultation.

B. A heart murmur is not caused by blood entering an inflexible chamber. Instead, it is caused by turbulent blood flow through the heart valves. The sound produced by this turbulent flow may vary depending on the underlying pathology of the valve.

C. While heart murmurs can be described based on their characteristics (such as high-pitched or low- pitched), the presence of a heart murmur does not necessarily indicate a narrow valve. Murmurs can occur due to various valve abnormalities, including stenosis (narrowing) or regurgitation (leakage). The pitch and quality of the murmur may vary depending on the underlying pathology and the location of the abnormality.

D. A heart murmur is not typically associated with inflammation around the heart. While inflammation of the heart (such as myocarditis or pericarditis) can cause symptoms and abnormal sounds, these conditions would not be described specifically as a "heart murmur."

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Correct Answer is B

Explanation

B. Assessing the client's vital signs, including blood pressure and pulse, provides critical information about the client's hemodynamic status and response to the new rhythm. Atrial fibrillation can lead to rapid, irregular heart rates and hemodynamic instability, so obtaining vital signs promptly helps the nurse determine the severity of the situation and whether immediate intervention is needed.

A. This action is not the priority when the nurse observes a new onset of atrial fibrillation. While beta- blockers such as metoprolol may be part of the client's long-term management for heart failure and atrial fibrillation, initiating medication administration without further assessment could delay appropriate intervention for the acute change in rhythm.

C. While it is important to communicate changes in the client's condition to the healthcare provider, this action should occur after the nurse has assessed the client's vital signs and determined the urgency of the situation. If the client is stable and responsive to initial interventions, the nurse can then contact the healthcare provider to discuss the new onset of atrial fibrillation and collaborate on further management.

D. Documenting the changes in the client's rhythm is important for continuity of care and communication among healthcare team members. However, obtaining a rhythm strip should not be the first action when a new onset of atrial fibrillation is observed. Assessing the client's vital signs and initiating appropriate interventions to address any hemodynamic instability take precedence.

A. Position the head of the client's bed in the flat position. B. Provide humidity by maintaining moisture within the ventilator tubing. C. Turn the client every 4 hr. D. Brush the client's teeth with a suction toothbrush every 12 hr.

Correct Answer is D

Explanation

D. Oral hygiene is crucial in reducing the risk of VAP as it helps to reduce the bacterial load in the oral cavity, which can be aspirated into the lower respiratory tract. Using a suction toothbrush to mechanically remove dental plaque and bacteria from the teeth and oral mucosa can help to prevent VAP.

A. Elevating the head of the bed to between 30 and 45 degrees (semi-recumbent position) is recommended to prevent aspiration of oral or gastric contents, which can contribute to the development of VAP. This position helps to promote drainage of secretions and reduces the risk of reflux.

B. While maintaining appropriate humidity levels in the ventilator tubing helps to prevent drying of the respiratory mucosa and promote secretion clearance, it does not directly reduce the risk of VAP. Other interventions are more directly related to VAP prevention.

C. Regular turning and repositioning of the client help to prevent pooling of secretions, improve ventilation-perfusion matching, and reduce the risk of pressure ulcers. Turning the client every 2 hours is often recommended to optimize lung expansion and secretion clearance, thereby reducing the risk of VAP.

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A client tells the nurse that he is concerned because his provider told him he has a heart murmur. The nurse should explain to the client that a murmur

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a history of heart failure and notes a new onset of the following rhythm on the client's telemetry monitor. Which action would the nurse take first?

Correct Answer is B

Explanation

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator- associated pneumonia?

Correct Answer is D

Explanation

The nurse is caring for a patient receiving a continuous norepinephrine IV infusion. Which finding indicates that the infusion rate may need to be adjusted?

A nurse is caring for a client who is postoperative and whose respirations are shallow and 9/min. Which of the following acid-based imbalances should the nurse identify the client as being at risk for developing initially?

A nurse is caring for a client with a ventricular pacemaker who is on ECG monitoring. The nurse understands that the pacemaker is functioning properly when which of the following appears on the monitor strip?

Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires action by the nurse?

A client with acute respiratory distress syndrome (ARDS) shows no improvement despite increases in concentration in oxygen administered. What intervention should the nurse attempt which may improve ventilation-perfusion matching?

A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?