The nurse is performing an assessment of the clients lungs. The nurse recognizes that the left lung:

Consists of two lobes.

Primarily consists of an upper lobe on the posterior chest.

Is shorter than the right lung because of the underlying stomach.

is divided by the horizontal fissure.

Answer and Explanation

The Correct Answer is A

A. Consists of two lobes.

This statement is correct. The left lung consists of two lobes: the upper lobe and the lower lobe. The right lung, not the left lung, has three lobes: upper, middle, and lower lobes.

B. Primarily consists of an upper lobe on the posterior chest.

This statement is not accurate. The upper lobe of the left lung is present in the anterior and posterior parts of the chest. It is not limited to the posterior chest.

C. Is shorter than the right lung because of the underlying stomach.

This statement is not correct. The left lung is not shorter due to the underlying stomach. The left lung is slightly smaller than the right lung to accommodate the space for the heart, but this size difference is not due to the stomach.

D. Is divided by the horizontal fissure.

This statement is not accurate. The left lung is not divided by the horizontal fissure. The horizontal fissure is a feature of the right lung, not the left lung. The left lung is divided by the oblique fissure into the upper and lower lobes

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Correct Answer is A

Explanation

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).

A. Continue with the assessment, looking for any other abnormal findings. B. Refer the patient to a throat specialist. C. No response is needed; this appearance is normal for the tonsils. D. Obtain a throat culture on the patient for possible streptococcal (strep) infection.

Correct Answer is A

Explanation

A. Continue with the assessment, looking for any other abnormal findings: This is the correct response. Tonsils in adults can have various appearances, and a granular appearance with deep crypts is within the range of normal. It's essential for the nurse to continue the assessment and observe for other signs or symptoms that might indicate an issue.

B. Refer the patient to a throat specialist: Referring the patient based solely on the appearance of the tonsils, especially if it's a normal variant, might be unnecessary and could cause undue concern for the patient. It's important to assess the patient comprehensively before considering a specialist referral.

C. No response is needed; this appearance is normal for the tonsils: This is the correct explanation. In adults, tonsils often appear granular with deep crypts, which is considered a normal variation. No further action is required regarding the tonsils.

D. Obtain a throat culture on the patient for possible streptococcal (strep) infection: Based on the description provided (involution, granular appearance, and deep crypts), there's no specific indication of a streptococcal infection. Conducting a throat culture should be based on the presence of specific symptoms and signs indicative of a streptococcal infection, such as sore throat, fever, and swollen tonsils with white patches, rather than just the appearance of the tonsils.

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The nurse is performing an assessment of the clients lungs. The nurse recognizes that the left lung:

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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