The practical nurse (PN) is auscultating a client's heart sounds. Which abnormal heart sound should the PN report to the charge nurse? (Please listen to the audio file to select the option that applies.)
S4.
S2.
S1.
S3.
Correct Answer : A,D
S3 is an extra heart sound that occurs during diastole (the filling phase of the cardiac cycle). It is commonly associated with conditions such as heart failure and volume overload. S3 is often described as a low-frequency, dull, and distant sound heard after S2 (the second heart sound).
B, C- S1, and S2 are the normal heart sounds that are typically heard in all individuals. S1 is the first heart sound, heard as "lub," and is caused by the closure of the mitral and tricuspid valves. S2 is the second heart sound, heard as "dub," and is caused by the closure of the aortic and pulmonic valves. These sounds are normal and expected.
S4 is another abnormal heart sound, which occurs during late diastole and is associated with conditions such as ventricular hypertrophy and reduced ventricular compliance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E","H"]
Explanation
To identify the potential source of the client's new-onset confusion and decreased appetite, the nurse can use the following assessment techniques:
- Ask to see the client's list of home medications: This can help identify any medications that may contribute to confusion or appetite changes.
- Determine if the client has recently lost a loved one: Emotional distress, such as grief from a recent loss, can contribute to changes in mental status and appetite.
- Measure the client's vital signs: Vital signs can provide important information about the client's overall health status and help identify any abnormalities that may be contributing to the symptoms.
- Perform a 12-lead electrocardiogram: This can help assess the client's cardiac function and detect any cardiac-related causes for the symptoms.
- Ask about the client's last bowel movement: Changes in bowel habits can sometimes be indicative of underlying issues affecting appetite and overall health.
- Measure the client's abdominal circumference: This can help assess for any abdominal distension or changes that may be related to the client's symptoms.
Incorrect answers
- Collecting a sputum and urine culture and sensitivities and having the client ambulate across the room are not directly related to identifying the potential source of confusion and decreased appetite in this case.
Correct Answer is A
Explanation
A. Checking the child’s blood glucose level via fingerstick is the most important step before administering insulin to prevent hypoglycemia or ensure the appropriate dose.
B. Exercise affects blood sugar, but the immediate priority is verifying the blood glucose level.
C. Urination patterns can indicate hyperglycemia, but they are not the most critical factor before insulin administration.
D. Eating is important, but insulin dosing should be based on blood glucose readings and meal intake combined.
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