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 C
Explanation
The correct answer is C.
Choice A reason:
Repeating the heel stick for glucose in one hour is not the best first action because it delays necessary treatment and the infant's glucose could drop further, potentially causing harm.
Choice B reason:
Offering nipple feedings of 10% dextrose is not the initial treatment of choice for neonatal hypoglycemia. Oral dextrose gel may be used, but the priority is to provide a source of nutrition, such as breast milk or formula, which offers more sustained glucose levels.
Choice C reason:
Begin frequent feedings of breast milk or formula. This is the first intervention to implement because the infant's current glucose level is below the normal neonatal range of [30 to 60 mg/dL or 1.7 to 3.3 mmol/L], indicating hypoglycemia, which is common in infants of mothers with gestational diabetes. Immediate feeding can help raise the blood glucose level safely.
Choice D reason:
Assessing for signs of hypocalcemia is not the immediate priority. While hypocalcemia can occur in newborns, particularly those with maternal diabetes, the current symptoms and glucose level suggest hypoglycemia is the primary concern. Signs of hypocalcemia include irritability, muscle twitches, jitteriness, tremors, and poor feeding, which can overlap with hypoglycemia symptoms. However, the heel stick glucose level clearly indicates hypoglycemia, which should be addressed first.
Correct Answer is A
Explanation
Acne is a common skin condition that often requires professional evaluation and treatment by a dermatologist. While the other options may be part of a comprehensive acne management plan, they alone may not be sufficient to address the client's specific needs. The recommendation to refer the client to a dermatologist allows for a more comprehensive assessment and the implementation of appropriate long-term therapy tailored to the individual's condition. The dermatologist can prescribe medications, provide personalized skincare recommendations, and monitor the client's progress over time. This ensures that the client receives the most effective and appropriate treatment for their acne.
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