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. Tachycardia is a compensatory mechanism aimed at increasing cardiac output and maintaining tissue perfusion. In response to decreased perfusion, the body increases heart rate to improve circulation and oxygen delivery to tissues.
A. Hypokalemia, or low potassium levels, is not typically associated with the compensatory stage of shock. Instead, electrolyte imbalances may develop later in the progression of shock due to tissue hypoperfusion and metabolic disturbances.
C. Mottled skin, characterized by patchy discoloration due to uneven blood flow, is more commonly seen in the progressive or irreversible stages of shock. It indicates significant tissue hypoperfusion and impaired microcirculation, rather than the compensatory stage
D. This blood pressure reading is within the normal range and may be maintained during the compensatory stage of shock. Initially, blood pressure may be maintained or only slightly decreased due to compensatory mechanisms such as vasoconstriction. However, blood pressure can decrease further as shock progresses beyond the compensatory stage.

A. Decreased brain natriuretic peptide (BNP). B. Elevated central venous pressure (CVP). C. Decreased specific gravity D. Increased pulmonary artery wedge pressure (PAWP).

Correct Answer is B

Explanation

B. Right-sided heart failure leads to congestion of the systemic venous circulation, resulting in increased central venous pressure (CVP). Elevated CVP is a hallmark sign of right-sided heart failure and is often used clinically to assess right ventricular preload and volume status.

A. BNP is a hormone secreted by the heart in response to increased ventricular stretch and volume overload, and its levels are usually elevated in heart failure, including both left-sided and right-sided heart failure.

C. Specific gravity refers to the concentration of solutes in urine and is often used as a measure of urine concentration.

D. Pulmonary artery wedge pressure (PAWP) is a measure of left atrial pressure and left ventricular end- diastolic pressure. In right-sided heart failure, the primary hemodynamic abnormality is congestion of the systemic venous circulation, rather than elevated left-sided pressures.

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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

A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse in a cardiac care unit is caring for a client with acute right-sided heart failure. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

Norepinephrine has been prescribed for a patient who was admitted with dehydration and hypotension. Which data indicate that the nurse should consult with the health care provider before starting the norepinephrine?

A nurse is caring for a client in a critical care unit who suffered a knife wound to the chest. The nurse suspects the client is developing cardiac tamponade. Which of the following assessment findings should the nurse identify as supporting this suspicion?

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?

A nurse in an urgent care center is assessing a client who reports a sudden onset of irregular palpitations, fatigue, and dizziness. The nurse finds a rapid and irregular heart rate with a significant pulse deficit. Which of the following dysrhythmias should the nurse expect to find on the ECG?

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?

The rapid response team (RRT) is caring for a client with asystole. Which nursing statement made to the client's family about the actions of the RRT is appropriate?

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 patient with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2) of 78%. The patient is increasingly lethargic. Which intervention will the nurse anticipate?