The practical nurse (PN) is auscultating a client’s heart sounds. Which heart sounds are considered abnormal findings that should be reported to the charge nurse?
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 D
Explanation
Dry mucous membranes and a dry mouth are common side effects of anticholinergic drugs like dicyclomine. These medications block the action of acetylcholine, a neurotransmitter responsible for stimulating secretions in the body. As a result, the client may experience dryness in various parts of the body, including the mouth.
Providing oral care, such as offering the client sips of water or providing a moistening agent for the mouth, can help alleviate the discomfort caused by dryness and promote oral hygiene. It is an appropriate and immediate intervention for the client's current symptoms.
Incorrect:
A. Checking vital signs may not directly address the client's dry mouth, but it is a good practice to assess the client's overall condition.
B. Monitoring hemoglobin would not be necessary in this situation, as it does not directly relate to the client's dry mucous membranes.
C. Notifying the charge nurse may be appropriate if the client's symptoms worsen or if there are other concerning factors, but the priority action in this case is to provide oral care to address the client's discomfort.
Correct Answer is B
Explanation
Knowing the type of uterine incision from the previous cesarean section is crucial when considering the option of vaginal birth after cesarean (VBAC). The type of incision can provide important insights into the potential risks and complications associated with a trial of labor.
Specifically, a low transverse uterine incision is considered the most favorable for VBAC, as it has a lower risk of uterine rupture compared to other types of incisions, such as a classical or vertical incision.
A. While information about the client's intent regarding breastfeeding of the newborn is important for providing appropriate support and education, it does not have a direct impact on the decision-making process for VBAC.
C. A history of contracting Herpes simplex virus is relevant to the client's overall health and may have implications for the management of the pregnancy, but it is not directly related to the decision regarding VBAC.
D. The religious preference of the client's family, while important for respecting cultural and spiritual beliefs, does not have a direct impact on the decision-making process for VBAC.
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