The nurse is on the medical/surgical floor is getting a new admission. The client is being admitted for shortness of breath (dyspnea). Which assessment finding would be of concern?

Respiratory rate of 20

Vesicular sounds heard in the lung periphery

Capillary refill time of 5 seconds

AP diameter of 1:2

Equal chest expansion

Answer and Explanation

The Correct Answer is C

A. A respiratory rate of 20 is within the normal range for adults (12-20 breaths per minute), especially in someone experiencing dyspnea.
B. Vesicular sounds in the lung periphery are normal findings, particularly in healthy lung areas.
C. A capillary refill time of 5 seconds indicates poor perfusion and could suggest systemic issues or hypoxia, which is concerning in a patient with dyspnea.
D. An anteroposterior (AP) diameter of 1:2 is normal; a barrel chest might indicate chronic respiratory conditions but is not an immediate concern in this context.
E. Equal chest expansion is a normal finding and indicates effective respiratory mechanics.

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Correct Answer is B

Explanation

A. This option incorrectly includes the aortic valve rather than the tricuspid valve in the S1 heart sound.
B. S1 represents the closure of the mitral and tricuspid valves, which occurs at the beginning of ventricular systole and produces the "lub" sound.
C. The pulmonic valve closure is associated with the S2 heart sound, not S1.
D. The closure of the pulmonic and aortic valves occurs in S2, not S1.
E. This combination is incorrect, as S1 is associated with mitral and tricuspid valve closure.

A. Auscultate for any cardiac murmurs B. Compare the apical and radial pulse rates C. Palpate the quality of the peripheral pulses D. Find the point of maximal impulse E. Check capillary refill time

Correct Answer is A

Explanation

A. Auscultate for any cardiac murmurs is correct, as a thrill often indicates turbulent blood flow, which may correlate with murmurs that can be heard upon auscultation.
B. Comparing apical and radial pulse rates is useful in assessing pulse deficits but does not directly address the cause of the thrill.
C. Palpating the quality of the peripheral pulses does not provide specific information about the thrill's origin.
D. Finding the point of maximal impulse is a useful cardiac assessment but does not directly explain the cause of the thrill.
E. Checking capillary refill time assesses peripheral perfusion but does not relate to the thrill's cause.

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The nurse is on the medical/surgical floor is getting a new admission. The client is being admitted for shortness of breath (dyspnea). Which assessment finding would be of concern?

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Naxlex Comprehensive Predictor Exams

The nurse is asked to describe what the heart sound S1 represents. What would be the correct response by the nurse?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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