A nurse is collecting data about a client's cardiac functioning. The nurse auscultates an S3 sound. Which of the following causes should the nurse suspect?

Atrial gallop

Ventricular gallop

Closing of semilunar valves

Closing of the atrioventricular valves

Answer and Explanation

The Correct Answer is B

A. Atrial gallop: An atrial gallop is associated with the S4 heart sound, which occurs before the S1 sound due to the atrial contraction.

B. Ventricular gallop: An S3 heart sound is known as a ventricular gallop and is often a sign of heart failure or fluid overload. It occurs during early diastole when the ventricle fills rapidly.

C. Closing of semilunar valves: The closing of the semilunar valves (aortic and pulmonary) produces the S2 heart sound, not the S3 sound.

D. Closing of the atrioventricular valves: The closing of the atrioventricular valves (mitral and tricuspid) produces the S1 heart sound, not the S3 sound.

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Correct Answer is A

Explanation

A. Check the client's distal pulses in both legs. It is important to assess distal pulses to ensure adequate circulation and to detect any signs of potential complications, such as arterial occlusion or hematoma formation, after cardiac catheterization.

B. Keep the client overnight. Most clients do not need to be kept overnight after cardiac catheterization unless there are complications. This option is unnecessary in routine cases.

C. Restrict the client's oral fluids. Clients are encouraged to increase oral fluids after the procedure to help flush out the contrast dye used during the catheterization and reduce the risk of kidney damage.

D. Keep the client on bed rest for 12 hr. Bed rest is required for a few hours (typically 4-6 hours) after cardiac catheterization to reduce the risk of bleeding from the puncture site. However, 12 hours of bed rest is generally not necessary unless there are specific complications.

A. Wrapping the cuff too loosely around the client's arm B. Positioning the client's arm above heart level C. Deflating the cuff too slowly D. Measuring blood pressure right after the client's mealtime

Correct Answer is B

Explanation

A. Wrapping the cuff too loosely around the client's arm: A loosely wrapped cuff can cause an inaccurately high reading, not a low one.

B. Positioning the client's arm above heart level: If the client’s arm is positioned above heart level, the blood pressure reading may be inaccurately low. Blood pressure measurements should always be taken with the arm at heart level.

C. Deflating the cuff too slowly: Deflating the cuff too slowly typically leads to an inaccurately high reading, not a low one.

D. Measuring blood pressure right after the client's mealtime: While digestion can sometimes cause a slight drop in blood pressure, it is not typically a significant factor in obtaining an unusually low reading.

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A nurse is collecting data about a client's cardiac functioning. The nurse auscultates an S3 sound. Which of the following causes should the nurse suspect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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