A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds?

A friction rub

A split second heart sound S₂

The third heart sound (S3)

The fourth heart sound (S4)

Answer and Explanation

The Correct Answer is D

A. A friction rub: A friction rub is a sound caused by the rubbing of inflamed pericardial layers and is not classified as a heart sound like S1 or S2. It is unrelated to the sequence of heart sounds.

B. A split second heart sound S₂: A split S₂ occurs during the closure of the aortic and pulmonary valves and is heard after S1, not before.

C. The third heart sound (S3): S3, or the ventricular gallop, occurs shortly after S2 during early diastole and indicates rapid ventricular filling. It is not heard before S1.

D. The fourth heart sound (S4): S4, known as the "atrial gallop," occurs just before S1 during atrial contraction. It is associated with a stiff or hypertrophied ventricle and is often indicative of underlying heart disease, especially in older adults.

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Correct Answer is C

Explanation

A. Administer enteric-coated acetaminophen: Acetaminophen is not typically used to address the symptoms described by the client, such as pain in the jaw, back, and shoulder, shortness of breath, and nausea. Moreover, an enteric-coated form of acetaminophen is not likely to address the acute symptoms.

B. Administer ibuprofen: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) and may not be appropriate for the reported symptoms, especially if they are indicative of a cardiac event.

C. Obtain an EKG: This is the correct answer. The client's symptoms, including pain in the jaw, back, and shoulder, shortness of breath, and nausea, are concerning for a possible cardiac event, such as a myocardial infarction (heart attack). An electrocardiogram (EKG) is a crucial diagnostic tool to assess for cardiac abnormalities and should be done promptly.

D. Maintain oxygen saturations greater than or equal to 92%: While maintaining adequate oxygen saturation is important in various clinical situations, the client's symptoms, especially when associated with potential cardiac issues, warrant an immediate EKG to assess for cardiac abnormalities.

A. Nausea B. Dysphagia C. Hypotension D. Agitation

Correct Answer is D

Explanation

A. Nausea: While respiratory distress can lead to various symptoms, nausea is not a typical manifestation of hypoxemia during an asthma attack.

B. Dysphagia: Difficulty swallowing (dysphagia) is not a direct manifestation of hypoxemia during an asthma attack. Asthma primarily affects the airways and respiratory function.

C. Hypotension: Hypotension (low blood pressure) is not typically associated with hypoxemia during an asthma attack. In fact, increased respiratory effort and stress can lead to increased heart rate and, in some cases, increased blood pressure.

D. Agitation: This is the correct answer. Hypoxemia, which occurs when there is an inadequate amount of oxygen in the blood, can lead to increased restlessness, anxiety, and agitation. Agitation is a common manifestation of the body's response to insufficient oxygenation.

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A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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