A nurse is collecting data from a client who has anemia due to excess blood loss during surgery causing a decrease in blood flow/perfusion in the patient. The patient's vital signs are as follows: BP 100/60. HR 122. Resp 24, SPO2 92%. The nurse should expect which of the following findings/symptoms?

Dyspnea on exertion

Respiratory depression

Intense abdominal pain

Bradycardia

Answer and Explanation

The Correct Answer is A

A. Dyspnea on exertion: Anemia from blood loss reduces oxygen-carrying capacity, leading to symptoms like fatigue and dyspnea on exertion. The patient's low SpO₂, tachycardia, and increased respiratory rate are consistent with this finding.

B. Respiratory depression: Respiratory depression is typically associated with narcotics or other depressants, not anemia due to blood loss. The increased respiratory rate suggests a compensatory mechanism for decreased oxygenation, not depression.

C. Intense abdominal pain: While abdominal pain could be present in some conditions, it is not a direct symptom of anemia due to surgical blood loss and decreased perfusion.

D. Bradycardia: Anemia usually causes tachycardia (increased heart rate) as the body compensates for the decreased oxygenation, not bradycardia (slow heart rate). Therefore, bradycardia is unlikely in this case.

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Correct Answer is B

Explanation

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.

A. A systolic murmur B. A third heart sound (S3) C. A fourth heart sound (S4) D. An expected heart sound

Correct Answer is A

Explanation

A. A systolic murmur: A murmur heard between S1 and S2 occurs during systole, which is why it is classified as a systolic murmur. Systolic murmurs are often due to valve abnormalities like aortic stenosis or mitral regurgitation.

B. A third heart sound (S3): The S3 sound occurs after S2, not between S1 and S2. It is associated with rapid ventricular filling and may indicate heart failure.

C. A fourth heart sound (S4): The S4 sound occurs before S1, not between S1 and S2. It is associated with a stiff or hypertrophic ventricle.

D. An expected heart sound: A murmur is not considered an expected heart sound; it is typically abnormal and requires further investigation.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

While auscultating a client's heart sounds, the nurse hears turbulence between S1 and S2. The nurse should document this finding as which of the following?

Correct Answer is A

Explanation

A nurse is reinforcing teaching about a heart healthy diet with a group of clients who have hypertension. Which of the following statements by the clients indicates a need for further teaching?

The nurse notes the patient’s lower legs are brown and discolored and their feet are cold and slightly blue in color when in the dependent position. Which of the following actions should the nurse take?

A nurse is counting a client's apical pulse rate. Identify where the nurse should place the stethoscope to auscultate the apical pulse. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

A nurse is assisting with the care of a client 2 hr postoperative following a cardiac catheterization. Which of the following actions should the nurse take?

A nurse is administering nicardipine to a client who has a BP of 180/120 mm Hg. Which of the following actions should the nurse take first?

A nurse is monitoring a client's peripheral circulation. Identify where the nurse should palpate to check the posterior tibial pulse. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?

A nurse is reviewing the prescriptions for a newly admitted client who is to undergo cardiac testing. For which of the following procedures should the nurse verify that the client has given written informed consent?