While auscultating a client's heart sounds, the nurse hears turbulence between S1 and S2. The nurse should document this finding as which of the following?

A systolic murmur

A third heart sound (S3)

A fourth heart sound (S4)

An expected heart sound

Answer and Explanation

The Correct Answer is A

A. A systolic murmur: A murmur heard between S1 and S2 occurs during systole, which is why it is classified as a systolic murmur. Systolic murmurs are often due to valve abnormalities like aortic stenosis or mitral regurgitation.

B. A third heart sound (S3): The S3 sound occurs after S2, not between S1 and S2. It is associated with rapid ventricular filling and may indicate heart failure.

C. A fourth heart sound (S4): The S4 sound occurs before S1, not between S1 and S2. It is associated with a stiff or hypertrophic ventricle.

D. An expected heart sound: A murmur is not considered an expected heart sound; it is typically abnormal and requires further investigation.

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Correct Answer is B

Explanation

A. 108/60 mm Hg: This is considered normal blood pressure and does not indicate hypertension.

B. 134/86 mm Hg: According to the current guidelines, stage 1 hypertension is defined as systolic 130-139 mm Hg or diastolic 80-89 mm Hg. This client's blood pressure falls into that category.

C. 164/104 mm Hg: This is classified as stage 2 hypertension, which is defined by systolic BP ≥ 140 mm Hg or diastolic BP ≥ 90 mm Hg.

D. 128/68 mm Hg: This is considered elevated blood pressure, not stage 1 hypertension. Stage 1 begins at systolic BP of 130 mm Hg.

A. Check the client's distal pulses in both legs. B. Keep the client overnight. C. Restrict the client's oral fluids. D. Keep the client on bed rest for 12 hr.

Correct Answer is A

Explanation

A. Check the client's distal pulses in both legs. It is important to assess distal pulses to ensure adequate circulation and to detect any signs of potential complications, such as arterial occlusion or hematoma formation, after cardiac catheterization.

B. Keep the client overnight. Most clients do not need to be kept overnight after cardiac catheterization unless there are complications. This option is unnecessary in routine cases.

C. Restrict the client's oral fluids. Clients are encouraged to increase oral fluids after the procedure to help flush out the contrast dye used during the catheterization and reduce the risk of kidney damage.

D. Keep the client on bed rest for 12 hr. Bed rest is required for a few hours (typically 4-6 hours) after cardiac catheterization to reduce the risk of bleeding from the puncture site. However, 12 hours of bed rest is generally not necessary unless there are specific complications.

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While auscultating a client's heart sounds, the nurse hears turbulence between S1 and S2. The nurse should document this finding as which of the following?

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Naxlex Comprehensive Predictor Exams

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