A client asks the nurse to describe what causes a murmur. What would be the correct response by the nurse?

"Poor electric impulse conduction through the heart"

"Turbulent blood flow through the heart valves"

"Enlargement of the left ventricle."

"Weak contraction of the atria."

"Long-term systemic hypertension."

Answer and Explanation

The Correct Answer is B

A. Poor electrical impulse conduction may lead to arrhythmias but does not cause a murmur.
B. A heart murmur is caused by turbulent blood flow, often through narrowed or leaking valves, creating an abnormal heart sound.
C. Left ventricular enlargement can contribute to other cardiac issues but does not directly cause murmurs.
D. Weak atrial contractions may lead to decreased cardiac output but not necessarily to a murmur.
E. While hypertension can affect the heart, it is not the direct cause of a murmur.

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Correct Answer is E

Explanation

A. Providing care based on predetermined criteria may overlook individual client needs and cultural nuances.
B. Prioritizing hospital unit workflow may not align with the individual needs of clients.
C. Care aligned with professional healthcare values may not address the specific cultural values and preferences of diverse clients.
D. This approach may dismiss the client's autonomy and unique cultural context.
E. Honoring the client's differences and perspectives indicates a commitment to culturally responsive care, recognizing and respecting diverse backgrounds.

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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A client asks the nurse to describe what causes a murmur. What would be the correct response by the nurse?

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Naxlex Comprehensive Predictor Exams

A nurse is providing care to a culturally diverse population. Which action indicates the nurse is successful in the role of providing culturally responsive care?

Correct Answer is E

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

The RN and certified nursing assistant/patient care assistance (CNA/PCA) are caring for five clients on a medical/surgical unit. Which of the following tasks would be most appropriate for the nurse to delegate to the CNA/PCA?

The nurse receives orders for an opiate pain medication for a client with severe pain. What other order does the nurse anticipate getting?

When performing a focused cardiac assessment on a newly admitted client, the nurse notes a heave on the left side of the chest. What can a heave signify?

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

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?

The nurse obtains information when performing a focused assessment of a client with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea (shortness of breath) over the last 3 days. Which finding is most important to report to the health care provider?

The nurse is percussing over the lungs of a client with pneumonia. What sound will the nurse expect to hear?

A nurse is providing care to a culturally diverse population. Which action indicates the nurse is successful in the role of providing culturally responsive care?