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 B

Explanation

A. "The medication can take up to 15 minutes to take effect." - This statement is not accurate, sublingual nitroglycerin works rapidly and often provides relief within a few minutes.

B. Sublingual nitroglycerin is administered by placing the tablet under the tongue, and it should be allowed to dissolve or be absorbed directly into the bloodstream through the mucous membranes. It is not swallowed or chewed. The small sip of water can help facilitate the dissolving process.

C. "Avoid taking the medication prior to exercising." - This statement is not accurate. Nitroglycerin can be taken before anticipated exertion or activities that may trigger angina to prevent anginal episodes during physical activity.

D. "Stop taking the medication and notify your provider if you develop a headache." - While headaches are a common side effect of nitroglycerin, they are generally transient and not a reason to stop taking the medication. Persistent or severe headaches should be reported to the healthcare provider.

A. Disorientation B. Barrel-shaped chest C. Yellow sputum D. Nebulizer use E. Ankle edema F. SaO2 92% G. Clubbing of fingers

Correct Answer is ["A","B","C","E","F"]

Explanation

A. Disorientation:

This may indicate a neurological or cognitive issue and requires further assessment.

B. Barrel-shaped chest:

This is a characteristic finding in COPD, but any change or worsening may need evaluation.

C. Yellow sputum:

Yellow or greenish sputum may indicate an infection, and follow-up is needed.

D. Nebulizer use:

Nebulizer use is part of the prescribed treatment.

E. Ankle edema:

Edema can be a sign of heart failure or other cardiovascular issues and should be investigated.

F. SaO2 92%:

Oxygen saturation of 92% is below the normal range. It may indicate respiratory compromise and needs attention.

G. Clubbing of fingers:

While clubbing can be associated with chronic respiratory conditions, it is not an immediate concern.

H. Lives alone:

Living alone may impact the client's support system but does not require immediate medical attention.

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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

A nurse is providing instructions to a client who has a new prescription for sublingual nitroglycerin (Nitrostat) to treat angina pectoris. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

A nurse is caring for a client who has COPD. Medication Indacaterol 75 mcg, one inhalation daily Acetylcysteine 20% solution 3 to 5 ml nebulizer every 6 to 8 hr while awake Select the 5 findings that require follow-up.

Correct Answer is ["A","B","C","E","F"]

Explanation

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