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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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Encourage oral fluids: While hydration is important, it is not the most immediate concern following the administration of prazosin.

B. Record the client's weight: Weight monitoring is not specifically indicated after the initial dose of prazosin and is not a priority action in this context.

C. Take a pulse oximetry reading: While monitoring oxygen saturation is important in many situations, it is not directly related to the administration of prazosin, which primarily affects blood pressure.

D. Place the call bell in reach of the client: This is the most appropriate action. Prazosin can cause orthostatic hypotension, particularly after the first dose, leading to dizziness or fainting. Ensuring that the call bell is within reach allows the client to request help if they feel lightheaded or need assistance.

Correct Answer is ["480"]

Explanation

To calculate the infusion rate, you need to determine the total volume to be infused and the time over which it will be infused.

Total volume to be infused = 200 mL

Time for infusion = 25 minutes

Infusion rate = Total volume / Time Infusion rate = 200 mL / 25 minutes = 8 mL/min

To convert this to mL/hour (since infusion pumps are typically set in mL/hour): Infusion rate = 8 mL/min × 60 minutes/hour = 480 mL/hour

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

Correct Answer is D

Explanation

A client is ordered to receive a bolus of 200 mL of NSS in 25 minutes. At what rate should the nurse set the IV pump?

Correct Answer is ["480"]

Explanation

The nurse administers losartan 50 mg PO to a client. One hour after administration, the client calls the nurse and complains of tingling of the lips. Noting that the client's lips are edematous, the nurse recognizes that the client is experiencing which issue?

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