The nurse auscultates a loud heart murmur while performing a cardiac assessment on a client. The nurse is aware that a heart murmur reflects:

increased fluid in the pericardial sac.

dysfunction of one or more heart valves.

an aneurysm of the descending aorta.

an occlusion of the right coronary artery.

Answer and Explanation

The Correct Answer is B

A. increased fluid in the pericardial sac: While fluid accumulation can affect heart sounds, it typically leads to muffled heart sounds rather than a loud murmur. Increased fluid in the pericardial sac (pericardial effusion) usually does not produce a classic heart murmur.

B. dysfunction of one or more heart valves: This statement is correct. Heart murmurs are often caused by turbulence in blood flow due to the dysfunction of heart valves, such as stenosis (narrowing) or regurgitation (leaking). A loud murmur suggests significant turbulence, which is often indicative of valvular heart disease.

C. an aneurysm of the descending aorta: While an aortic aneurysm can cause other types of heart sounds or signs of cardiovascular compromise, it is not primarily associated with heart murmurs.

D. an occlusion of the right coronary artery: An occlusion may lead to ischemia or myocardial infarction, which can cause changes in heart sounds, but it does not directly cause a heart murmur. Murmurs are more specifically related to blood flow dynamics, particularly involving valves.

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Correct Answer is ["C","D","E"]

Explanation

A. Decrease fluid intake of 1000 mL/day to prevent fluid overload: This goal is not appropriate. Clients with sickle cell crisis often require increased fluid intake to prevent dehydration and promote circulation, so limiting fluids is counterproductive.

B. The client verbalizes the procedure for a 24-hour urine collection: While understanding this procedure may be relevant for monitoring kidney function or hydration status, it is not a priority goal directly related to managing sickle cell crisis.
C. Oxygenation and perfusion to meet cellular and metabolic needs: Ensuring adequate oxygenation and perfusion is crucial in managing sickle cell crisis, as compromised blood flow can exacerbate pain and lead to further complications.

D. Complications are prevented or minimized: Preventing complications, such as infections or acute chest syndrome, is a key goal in managing a client with sickle cell disease, making this a critical aspect of discharge planning.

E. Pain is relieved or controlled: Pain management is a primary focus during a sickle cell crisis. Ensuring that pain is effectively managed before discharge is essential for the client's comfort and overall well-being.

A. Total cholesterol 198 mg/dL B. Low density lipoprotein (LDL) 90 mg/dL C. Serum albumin 6 g/L D. Alanine aminotransferase (ALT) 25 units/L

Correct Answer is B

Explanation

A) Total cholesterol 198 mg/dL: While this value is within normal limits, it does not specifically indicate the effectiveness of atorvastatin treatment, which primarily aims to lower LDL levels. An optimal outcome would focus more on the LDL reduction rather than total cholesterol alone.

B) Low density lipoprotein (LDL) 90 mg/dL: This finding indicates an expected outcome of atorvastatin therapy. Atorvastatin is effective at lowering LDL cholesterol, which is a key target in managing hyperlipidemia and reducing the risk of cardiovascular events. An LDL level below 100 mg/dL is generally considered optimal.

C) Serum albumin 6 g/L: This value is low and indicates potential malnutrition or liver dysfunction, which are not expected outcomes for a client on atorvastatin. A normal serum albumin level typically ranges from 3.5 to 5.0 g/dL, so this finding is concerning.

D) Alanine aminotransferase (ALT) 25 units/L: While this ALT level is within the normal range, it does not directly reflect the primary goal of atorvastatin therapy, which is to lower LDL cholesterol. Monitoring liver enzymes is important, but the expected outcome would be more clearly indicated by improved lipid profiles, particularly LDL levels.

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The nurse auscultates a loud heart murmur while performing a cardiac assessment on a client. The nurse is aware that a heart murmur reflects:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse caring for the client diagnosed with sickle cell crisis places priority on which specific goal(s) prior to discharge? (SELECT ALL THAT APPLY)

Correct Answer is ["C","D","E"]

Explanation

The nurse evaluates a client's response to the prescribed atorvastatin. Which finding indicates an expected outcome?

Correct Answer is B

Explanation

In preparation for a client having a Schilling test the nurse should explain that the test:

The nurse administers the first dose of prazosin 1 mg PO to a client. Which nursing action is most appropriate following the administration of this medication?

The nurse is conducting dietary teaching for a client diagnosed with coronary artery disease. Which statement made by the client indicates an understanding of fat sources and the need to limit saturated fats?

The nurse auscultates a loud heart murmur while performing a cardiac assessment on a client. The nurse is aware that a heart murmur reflects:

The nurse who is providing instructions to a client with hypertension will stress that it is most important to:

The client diagnosed with Vitamin B12 deficiency presents to the outpatient department for the follow up evaluation. Which nursing assessment finding indicates that the treatment has been effective? The client:

A client has recently started ferrous sulfate 500 mg by mouth two times per day for anemia. Which of the following data would indicate to the nurse that the therapy is successful?

The nurse recognizes that which diagnostic test is used to detect the most common cause of chronic iron deficiency anemia?