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. Using the incentive spirometer is primarily aimed at preventing respiratory complications, not directly related to DVT prevention.
B. Dangling the legs off the bed promotes blood flow and prepares the client for ambulation, which helps prevent venous stasis and reduces the risk of DVT.
C. Encouraging ambulation is crucial for DVT prevention, but this task typically requires nursing judgment and assessment.
D. Keeping the knees elevated for prolonged periods may increase the risk of venous stasis, potentially contributing to DVT formation.
E. Limiting fluids without a clinical indication can lead to dehydration, which may increase the risk of blood clots.

A. Hyperresonance B. Bubbling C. Tympany D. Dullness E. Resonance

Correct Answer is D

Explanation

A. Hyperresonance is often heard in cases of pneumothorax or emphysema, not pneumonia.
B. Bubbling is not a percussed sound but rather a description of breath sounds or fluid.
C. Tympany is typically heard over hollow organs like the stomach and is not expected in lung assessment.
D. Dullness over lung tissue indicates fluid or consolidation, as seen in pneumonia.
E. Resonance is normal over healthy lung tissue but would not be expected over areas of consolidation.

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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

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