A nurse is performing a focused assessment for a client who has a dysrhythmia. Which of the following findings indicates ineffective cardiac contractions?
Carotid bruit
Heart murmur
Pulse deficit
Bounding radial pulse
The Correct Answer is C
A. Carotid bruit – A carotid bruit is a vascular sound heard over the carotid artery due to narrowing (stenosis), not an indication of ineffective cardiac contractions.
B. Heart murmur – A heart murmur is caused by abnormal blood flow through heart valves and does not directly indicate ineffective cardiac contractions.
C. Pulse deficit – A pulse deficit occurs when there is a difference between apical and radial pulse rates, indicating ineffective cardiac contractions and poor cardiac output.
D. Bounding radial pulse – A bounding pulse suggests excessive cardiac output or fluid overload, not ineffective contractions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Pulse oximetry reading of 95%. COPD clients often have lower baseline oxygen levels (88-92%), making this reading unexpectedly high.
B. Decreased depth of respirations. COPD typically causes shallow and rapid breathing due to air trapping.
C. Flaring of the nostrils: Nostril flaring is a sign of increased respiratory effort, which is common in COPD exacerbations.
D. Respiratory rate of 16/min. → Normal range (12-20/min), not an expected finding during dyspnea.
Correct Answer is A
Explanation
A. "The body produces antibodies in response to an antigen with active immunity." Active immunity develops after exposure to an antigen, leading to antibody production.
B. "There is lifelong immunity with passive immunity." Passive immunity is temporary (e.g., maternal antibodies).
C. "The body is able to recognize previous exposure to antigens with passive immunity." Passive immunity does not create immune memory.
D. "There is a short duration of immunity with active immunity." Active immunity is long-lasting and sometimes lifelong.
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