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)
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Wearing loose, non-constricting stockings: This instruction is not recommended for a client with DVT. Compression stockings, which are snug-fitting, may be prescribed to prevent DVT, but loose stockings would not provide the necessary compression.
B. Applying cool compresses to her legs: Cool compresses are not typically recommended for DVT. Warm compresses may be used to improve blood circulation, but cold compresses may not be suitable.
C. Taking an NSAID tablet daily: Nonsteroidal anti-inflammatory drugs (NSAIDs) are not typically recommended for individuals with DVT, especially when on anticoagulant therapy, as they may increase the risk of bleeding.
D. Flexing her knees and feet frequently: This is the correct answer. Encouraging the client to flex her knees and feet frequently helps promote blood circulation and reduces the risk of venous stasis, which can contribute to the formation of blood clots. It is a beneficial measure for clients with DVT.
Correct Answer is D
Explanation
A. Restrict the client's fluid intake: There is typically no need to restrict fluid intake after a cardiac catheterization. Adequate hydration is important for preventing complications and promoting recovery.
B. Ambulate the client 1 hr following the procedure: While early ambulation is encouraged in many cases, the timing may vary based on the specific protocols of the healthcare provider. It is important to follow the healthcare provider's orders regarding post-catheterization ambulation.
C. Instruct the client to perform range-of-motion exercises to his lower extremities: Range-of-motion exercises are beneficial to prevent complications such as venous stasis and deep vein thrombosis. However, the specific exercises and timing may vary. It is important to follow the healthcare provider's instructions.
D. Perform neurovascular checks with vital signs: This is the correct answer. After a cardiac catheterization accessed through the femoral artery, it is crucial to monitor neurovascular status in the affected extremity. Assessing peripheral pulses, skin color, temperature, and capillary refill, along with monitoring vital signs, helps detect any signs of complications such as bleeding or vascular compromise.
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