The nurse is performing a focused cardiovascular assessment on a 70-year-old client. What finding would be considered abnormal? No palpable vibration felt over the precordium (chest wall)

S1 and S2 heard with diaphragm of stethoscope

A blowing sound heard over the mitral area with the bell of the stethoscope

Apical pulse palpated at 5th intercostal space, midclavicular line

Absent sound over carotid arteries with bell of the stethoscope

Answer and Explanation

The Correct Answer is B

A. S1 and S2 heard with the diaphragm of the stethoscope is a normal finding, as these are the expected heart sounds.
B. A blowing sound heard over the mitral area with the bell of the stethoscope suggests a possible murmur, which could indicate valvular abnormalities and is considered abnormal.
C. Apical pulse palpated at the 5th intercostal space, midclavicular line is normal and expected in adults.
D. Absence of sound over carotid arteries with the bell of the stethoscope indicates no bruits and is considered normal.

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Correct Answer is A

Explanation

A. Suctioning the tracheostomy is the priority action to clear secretions, which is likely the cause of the noisy, bubbly respirations. This can help the client breathe more easily.
B. Changing the tracheostomy tube is only necessary if the tube is obstructed or malfunctioning, and suctioning is generally the first step.
C. Notifying the healthcare provider may be needed if suctioning is ineffective or if complications persist, but immediate intervention is required.
D. Changing the tracheostomy dressing does not address the respiratory noise or potential secretion buildup.
E. A head-to-toe assessment may be needed, but the immediate concern is clearing the airway obstruction.

Correct Answer is ["15"]

Explanation

The pack-year amount for a patient who has smoked 10 cigarettes per day for 30 years is calculated as follows: one pack-year is equivalent to smoking 20 cigarettes, which is one pack, every day for one year. Therefore, 10 cigarettes per day is half a pack, and over 30 years, this equates to 15 pack-years (0.5 pack/day * 30 years = 15 pack-years).

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The nurse is performing a focused cardiovascular assessment on a 70-year-old client. What finding would be considered abnormal? No palpable vibration felt over the precordium (chest wall)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A postoperative client with a tracheostomy tube in place suddenly begins have noisy, bubbly sounding respirations. What action should the nurse take first?

Correct Answer is A

Explanation

The nurse is caring for a client admitted with pneumonia. The patient has a history of smoking 10 cigarettes per day for 30 years. What is the pack year amount? Use numbers only in your answer. No letters.

Correct Answer is ["15"]

Explanation

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