A nursing student is preforming a head-to-toe assessment on his patient with a history of mitral regurgitation. Instead of hearing normal heart sounds the student hears a murmur.

Which of the following best describes the sound of a heart murmur?

Lub-dub sounds

Gentle blowing or swooshing noise

Scratchy, leathery heart noise

Abrupt, high-pitched snapping noise

Answer and Explanation

The Correct Answer is B

A. Lub-dub sounds:

This describes the normal heart sounds, with the "lub" representing the closing of the mitral and tricuspid valves (S1) and the "dub" representing the closing of the aortic and pulmonic valves (S2). This is the typical and expected sound of a healthy heart.

B. Gentle blowing or swooshing noise:

This describes the characteristic sound of a heart murmur. Murmurs are abnormal sounds caused by turbulent blood flow, and they are often described as a gentle blowing or swooshing noise heard between the normal heart sounds.

C. Scratchy, leathery heart noise:

This description is not typical for heart sounds or murmurs. Heart sounds are usually described in terms of tones, clicks, or swooshing rather than scratchy or leathery.

D. Abrupt, high-pitched snapping noise:

This description is not typical for heart sounds or murmurs. Heart murmurs are generally characterized by a more continuous, blowing, or swooshing quality, rather than abrupt, high-pitched snapping noises.

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Correct Answer is D

Explanation

A. Develop a plan of care for the client:

Developing a plan of care is essential, but it should be informed by the client's current condition, diagnosis, and code status. Documenting the code status is a foundational step.

B. Provide a schedule of visiting hours to the client’s family:

While facilitating family involvement is important, it is not the top priority during the initial admission assessment. Ensuring the client's safety and understanding their code status takes precedence.

C. Teach the client about his diagnosis:

Patient education is important, but in a critical situation, the priority is to assess and document key information, including the code status. Education can follow once the immediate priorities are addressed.

D. Document the client’s code status

When conducting the initial admission assessment for a critical client, the priority action is to document the client's code status. Code status refers to the set of directives given by the client or their legal representative regarding the use of cardiopulmonary resuscitation (CPR) and other life-sustaining measures in the event of a cardiac or respiratory arrest.

Understanding and documenting the client's code status is crucial for informing the healthcare team about the client's preferences for resuscitation efforts. This information guides the team in providing care that aligns with the client's wishes and values.

Correct Answer is ["6"]

Explanation

To calculate the amount of ampicillin needed for one dose, we need to use a proportion. We can set up the proportion as follows:

150 mg / x mL = 125 mg / 5 mL

We can cross-multiply and solve for x:

150 * 5 = 125 * x

750 = 125 * x

x = 750 / 125

x = 6

Therefore, we need 6 mL of ampicillin for one dose

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A nursing student is preforming a head-to-toe assessment on his patient with a history of mitral regurgitation. Instead of hearing normal heart sounds the student hears a murmur. Which of the following best describes the sound of a heart murmur?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing the initial admission assessment and history for a critical client. Which of the following is the priority action for the nurse to take?

Correct Answer is D

Explanation

Order: Ampicillin (Principen) 150 mg PO every 6 hours Available: Ampicillin (Principen) 125mg per 5 ml How many mL of ampicillin are needed for one dose? ( Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero. TYPE THE ANSWER ONLY, no label )

Correct Answer is ["6"]

Explanation

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A nursing student is preforming a head-to-toe assessment on his patient with a history of mitral regurgitation. Instead of hearing normal heart sounds the student hears a murmur.

Which of the following best describes the sound of a heart murmur?