A nurse is examining a client with diastolic dysfunction. Upon auscultation using the bell of the stethoscope the nurse hears a late diastolic heart sound at the 5th intercostal space, left midclavicular line. Based on these findings and the clients history, the nurse would recognize this extra heart sound is most likely what?

Answer and Explanation

The Correct Answer is B

A. S1: S1 is the first heart sound, heard at the beginning of systole, and is not related to diastolic dysfunction.

B. S4: This is the correct answer. An S4 sound is heard late in diastole, often due to increased resistance to filling during diastole, which is typical in diastolic dysfunction.

C. S3: An S3 is a low-pitched sound heard early in diastole, typically associated with systolic dysfunction or heart failure with reduced ejection fraction.

D. S2: S2 is the second heart sound, heard during the end of systole and is not associated with diastolic dysfunction.

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Correct Answer is B

Explanation

A. The excitement of family does not indicate an infection risk. Emotional support can aid recovery.

B. Handling cat litter, which can contain bacteria, is a potential source of infection. Given the client's sternal wound, exposure to such bacteria increases the risk of infection, including sepsis.

C. Attending a party may present social interaction risks, but it is not as directly related to infection risk as handling cat litter.

D. Having the water turned on does not pose a significant risk for infection or sepsis.

A. Sinus Rhythm B. Ventricular Tachycardia C. Ventricular Fibrillation D. Sinus Tachycardia

Correct Answer is C

Explanation

A. Sinus rhythm is the normal rhythm of the heart with regular P waves, QRS complexes, and T waves. The presence of a sinus rhythm would mean the heart is pumping blood effectively, so the client would not be pulseless. This is inconsistent with the clinical scenario.

B. Ventricular tachycardia (VT) is a fast, regular rhythm originating in the ventricles. VT can lead to pulselessness if not treated, but it has distinct QRS complexes that are wide and regular, unlike the chaotic waveform seen in VF.

C. Ventricular Fibrillation appears as rapid, chaotic electrical activity without identifiable P waves, QRS complexes, or T waves. This rhythm prevents the heart from pumping blood, causing the client to be pulseless and unresponsive. VF is the most common arrhythmia associated with sudden cardiac arrest and requires immediate defibrillation.

D. Sinus tachycardia is a fast heart rate (>100 bpm) with regular rhythm, identifiable P waves, and QRS complexes. This rhythm typically occurs in response to stress, fever, or hypovolemia, and the client would have a pulse, which contradicts the scenario.

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Naxlex Comprehensive Predictor Exams

A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The client's sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge?

Correct Answer is B

Explanation

A nurse leaves a coffee shop and sees a man lying on the ground. He is unresponsive and has no pulse and the nurse begins chest compressions. EMS arrives and connects the cardiac monitor displaying this rhythm. Identify the rhythm.

Correct Answer is C

Explanation

A client who has chronic heart failure tells the nurse, "I was fine when I went to bed, but I woke up in the middle of the night feeling like I was suffocating!" The nurse will document this assessment finding as

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