The nurse is auscultating heart sounds on a client and hears an extra sound late in diastole, just before the S1. How should the nurse document this finding?

The third heart sound (S3)

A friction rub

The fourth heart sound (S4)

A split second heart sound S2

Answer and Explanation

The Correct Answer is A

A. The third heart sound (S3):

The third heart sound (S3) is an abnormal heart sound that occurs during early diastole, immediately after S2 (the second heart sound). It is caused by the rapid filling of the ventricles and is often associated with conditions like heart failure. In heart failure, the ventricles become stiff, causing vibrations that produce the S3 sound.

B. A friction rub:

A friction rub is a high-pitched, scratchy sound heard during both systole and diastole. It is caused by the rubbing together of inflamed pericardial layers (pericarditis) and is usually heard best at the left lower sternal border. Friction rubs can indicate pericardial inflammation and are often heard in conditions such as pericarditis or after a myocardial infarction.

C. The fourth heart sound (S4):

The fourth heart sound (S4) occurs late in diastole, just before S1, and is caused by atrial contraction. It is associated with increased resistance to ventricular filling, often due to conditions like hypertension or aortic stenosis. The S4 sound is heard as a low-pitched "atrial gallop."

D. A split second heart sound S2:

The second heart sound (S2) represents the closure of the aortic and pulmonic valves. Normally, S2 has two components: A2 (aortic valve closure) and P2 (pulmonic valve closure). A split S2 occurs when A2 and P2 do not close simultaneously. A physiological split S2 is common during inspiration and occurs due to delayed closure of the pulmonic valve. An abnormal or fixed split S2 can indicate underlying heart conditions such as atrial septal defect (ASD) or right bundle branch block (RBBB).

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Correct Answer is B

Explanation

A. Have the client breathe quickly:

This choice is incorrect because having the client breathe quickly is not a technique for assessing tactile fremitus. Tactile fremitus is assessed by feeling vibrations on the chest wall while the patient speaks, not during normal breathing.

B. Palpate the chest symmetrically:

This choice is correct. To assess tactile fremitus, the nurse places the palms or ulnar aspects of both hands firmly against the patient's chest while the patient speaks a phrase. The nurse should palpate the chest symmetrically to detect vibrations equally on both sides, which can help identify abnormalities in the lungs.

C. Ask the client to cough:

This choice is incorrect. Asking the client to cough is not a technique for assessing tactile fremitus. Tactile fremitus is evaluated by feeling vibrations while the patient speaks, not while coughing.

D. Use the bell of the stethoscope:

This choice is incorrect. Tactile fremitus is assessed by palpation, not auscultation with a stethoscope. Using the bell of the stethoscope is a technique for listening to low-pitched sounds, not for assessing tactile fremitus.

A. Aorta-Right atrium-right ventricle-pulmonary vein-lungs- pulmonary artery left atrium-left ventricle B. vena cava-right atrium-right ventricle-pulmonary vein-lungs- pulmonary artery-left atrium-left ventricle C. vena cava→ right atrium-right ventricle-pulmonary artery-lungs- pulmonary vein-left atrium-left ventricle D. Aorta-right atrium-right ventricle-lungs-pulmonary vein-left atrium-left ventricle- vena cava

Correct Answer is C

Explanation

In this sequence:

Vena cava brings deoxygenated blood from the body into the right atrium.

Blood flows from the right atrium to the right ventricle through the tricuspid valve.

The right ventricle pumps blood into the pulmonary artery to the lungs.

In the lungs, blood is oxygenated and returns to the heart via the pulmonary veins into the left atrium.

From the left atrium, blood moves to the left ventricle through the bicuspid (mitral) valve.

The left ventricle then pumps oxygenated blood into the body through the aorta.

This sequence represents the systemic and pulmonary circulation of the heart.

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The nurse is auscultating heart sounds on a client and hears an extra sound late in diastole, just before the S1. How should the nurse document this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is examining a client for tactile fremitus. The nurse recognizes that when examining for tactile fremitus it is important to:

Correct Answer is B

Explanation

The nurse is discussing the blood flow pattern of the heart. The nurse should recognize which of the following as the accurate blood flow pattern of the heart?

Correct Answer is C

Explanation

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