A nurse is auscultating a client's heart sounds and hears a third heart sound (S3). Which finding is consistent with the presence of an S3 sound in a client with congestive heart failure?

High-pitched, scratchy sound heard during inhalation

Extra heart sound heard immediately after S1 and S2

Prolonged, whooshing sound heard during systole

Irregular heart rhythm with varying intensity

Answer and Explanation

The Correct Answer is B

A) This choice is incorrect because a high-pitched, scratchy sound heard during inhalation is called a pleural friction rub and is associated with pleuritis or inflammation of the pleura, not congestive heart failure.

B) This choice is correct. An S3 heart sound is an extra heart sound heard immediately after S1 and S2, often described as a "ventricular gallop." It is associated with congestive heart failure and indicates increased fluid volume and strain on the ventricles.

C) This choice is incorrect because a prolonged, whooshing sound heard during systole is a heart murmur, which can be caused by various conditions, but it is not specific to the presence of an S3 sound.

D) This choice is incorrect because an irregular heart rhythm with varying intensity is characteristic of cardiac arrhythmias or irregular heartbeats and is not specific to the presence of an S3 sound.

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Correct Answer is C

Explanation

A) This choice is incorrect because a complete blood count (CBC) is a general blood test that measures different components of the blood, such as red blood cells, white blood cells, and platelets. It is not specifically used to measure heart strain or diagnose CHF.

B) This choice is incorrect because a basic metabolic panel (BMP) is a blood test that measures electrolytes, kidney function, and glucose levels. It is not specific to diagnosing CHF.

C) This choice is correct. A brain natriuretic peptide (BNP) level is a blood test specifically used to measure heart strain. Elevated BNP levels can indicate heart failure, making it a valuable diagnostic tool in assessing suspected CHF.

D) This choice is incorrect because a C-reactive protein (CRP) level is a marker of inflammation and is not specific to diagnosing CHF.

A. Take the medication with food to reduce stomach upset. B. Avoid using erectile dysfunction medications while on nitrate therapy. C. Avoid grapefruit juice while on nitrate therapy. D. Increase the dose if chest pain is not relieved within 15 minutes.

Correct Answer is B

Explanation

A) This choice is incorrect because taking the nitrate medication with food is not necessary. Nitrate medications are usually taken sublingually or by mouth and are not associated with significant stomach upset.

B) This choice is correct. Nitrate medications, such as nitroglycerin, can cause a dangerous drop in blood pressure when used concurrently with erectile dysfunction medications, specifically phosphodiesterase type 5 inhibitors (PDE5 inhibitors) like sildenafil (Viagra) or tadalafil (Cialis). Clients should be warned against using these medications together to prevent hypotension and potential cardiovascular complications.

C) This choice is incorrect because grapefruit juice is not typically associated with nitrate medications. Grapefruit juice can interact with certain medications, but it is not a known interaction with nitrates.

D) This choice is incorrect because increasing the nitrate dose without healthcare provider guidance can be dangerous. Clients should be instructed to take nitrate medications as prescribed and seek immediate medical attention if chest pain is not relieved within a specific timeframe, as directed by their healthcare provider.

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A nurse is auscultating a client's heart sounds and hears a third heart sound (S3). Which finding is consistent with the presence of an S3 sound in a client with congestive heart failure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with suspected congestive heart failure. Which blood test is specifically used to measure heart strain and assist in the diagnosis of CHF?

Correct Answer is C

Explanation

A client with congestive heart failure is prescribed a nitrate medication. The nurse should instruct the client to:

Correct Answer is B

Explanation

A client with congestive heart failure is prescribed spironolactone, a potassium-sparing diuretic. The nurse should instruct the client to:

A client with congestive heart failure reports waking up at night with sudden breathlessness and feeling the need to sit upright to breathe comfortably. The nurse should document this symptom as:

A client with congestive heart failure complains of feeling fatigued and weak after mild physical activity, such as getting dressed or walking short distances. The nurse should identify this symptom as:

A client with suspected congestive heart failure undergoes a chest X-ray. The nurse should anticipate which finding that may be indicative of CHF?

A client with a history of alcohol abuse and malnutrition is admitted with signs and symptoms of congestive heart failure. Which factor is likely a precipitating cause of the client's condition?

A nurse is providing education to a client diagnosed with congestive heart failure. The client asks, "What are the most common causes of CHF?" How should the nurse respond?

A nurse is assessing a client with suspected congestive heart failure. Which symptom is the classic hallmark of left-sided heart failure?

A nurse is providing discharge teaching to a client with congestive heart failure. The client is prescribed an angiotensin-converting enzyme (ACE) inhibitor. Which instruction is essential for the client to follow?