When performing a cardiovascular assessment, what would the nurse understand about an S3 heart sound? Select all that apply

Can be caused by a poorly compliant (stiff) ventricle

Can occur with congestive heart failure

Heard just after S1

Always pathologic

An expected finding in adolescents

Answer and Explanation

Correct Answer : A,B,E

A. An S3 is often associated with a stiff or poorly compliant ventricle.
B. An S3 heart sound can be an indication of congestive heart failure in adults, as it reflects increased fluid volume and pressure in the ventricles.
C. S3 is heard just after S2, not S1.
D. The S3 heart sound is not always pathologic. It is often benign in children, adolescents, and young adults, where it may occur due to a rapid filling phase of the ventricles.
E. In adolescents and younger individuals, an S3 heart sound is usually considered a normal finding.

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Correct Answer is B

Explanation

A. Venous insufficiency typically presents with swelling and pain that worsens with prolonged standing, not with exercise.
B. Claudication is the correct term, as it describes pain due to decreased blood flow to the muscles during exercise, often relieved by rest, which matches the patient's symptoms.
C. Muscle cramps may cause pain but are usually not consistently triggered by activity and relieved by rest.
D. Deep vein thrombosis would typically present with pain, swelling, warmth, and redness rather than exercise-induced pain relieved by rest.
E. Bruit from turbulent blood flow is an audible sound over an artery and not directly related to the type of pain described.

A. Suction the tracheostomy B. Change the tracheostomy tube C. Notify the healthcare provider D. Change the tracheostomy dressing E. Do a head to toe assessment

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.

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When performing a cardiovascular assessment, what would the nurse understand about an S3 heart sound? Select all that apply

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Naxlex Comprehensive Predictor Exams

A 67-year-old client states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for about 2 minutes, then he is able to resume his activities. How would the nurse document this finding?

Correct Answer is B

Explanation

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

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