A client tells the nurse that he is concerned because his provider told him he has a heart murmur. The nurse should explain to the client that a murmur

indicates turbulent blood flow through a valve.

is an extra sound due to blood entering an inflexible chamber.

is a high-pitched sound due to a narrow valve.

means that there is some inflammation around the heart.

Answer and Explanation

The Correct Answer is A

A. A heart murmur typically indicates turbulent blood flow through a heart valve. This turbulence can occur due to various reasons, such as valve stenosis (narrowing), regurgitation (leakage), or structural abnormalities of the valves. The turbulent flow produces audible sounds that can be heard with a stethoscope during cardiac auscultation.

B. A heart murmur is not caused by blood entering an inflexible chamber. Instead, it is caused by turbulent blood flow through the heart valves. The sound produced by this turbulent flow may vary depending on the underlying pathology of the valve.

C. While heart murmurs can be described based on their characteristics (such as high-pitched or low- pitched), the presence of a heart murmur does not necessarily indicate a narrow valve. Murmurs can occur due to various valve abnormalities, including stenosis (narrowing) or regurgitation (leakage). The pitch and quality of the murmur may vary depending on the underlying pathology and the location of the abnormality.

D. A heart murmur is not typically associated with inflammation around the heart. While inflammation of the heart (such as myocarditis or pericarditis) can cause symptoms and abnormal sounds, these conditions would not be described specifically as a "heart murmur."

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Correct Answer is A

Explanation

A The first intervention should be to ensure adequate oxygenation, as hypoxia can exacerbate shock. Therefore, providing oxygen at 100% via a non-rebreather mask is the most critical initial step. This intervention helps to maximize the amount of oxygen delivered to the patient's lungs and subsequently to the rest of the body, supporting vital organ function while further assessments and interventions are prepared.

B Continuous ECG monitoring allows for the assessment of the patient's heart rhythm, rate, and any signs of dysrhythmias or cardiac ischemia. This intervention is important for detecting any life- threatening arrhythmias, such as ventricular tachycardia or fibrillation, which may require immediate intervention. While ECG monitoring is important, it may not be the highest priority intervention.

C Drawing blood for type and crossmatch is important for preparing for potential blood transfusions if significant blood loss is suspected. However, this intervention may take some time to process, and immediate stabilization of the patient's condition is paramount.

D Large-bore IV catheters allow for rapid infusion of fluids to restore intravascular volume and improve tissue perfusion. This intervention is critical for stabilizing the patient's hemodynamic status and takes precedence in the management of shock. However, oxygenation should take priority.

A. Remove clothing for a thorough assessment. B. Determine effectiveness of ventilator efforts. C. Open the airway using a jaw-thrust maneuver. D. Establish IV access. E. Perform a Glasgow Coma Scale assessment.

Correct Answer is ["A","B","C","D","E"]

Explanation

First, the nurse should open the airway using a jaw-thrust maneuver (C) to ensure it is not obstructed. Next, they should determine the effectiveness of ventilatory efforts (B), as breathing is critical and any compromise must be addressed immediately. Following this, establishing IV access (D) is important for fluid resuscitation and medication administration. The nurse should then perform a Glasgow Coma Scale assessment (E) to determine the level of consciousness and neurological function. Lastly, removing clothing for a thorough assessment (A) is essential, but only after the critical steps concerning airway, breathing, circulation, and disability have been addressed.

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A client tells the nurse that he is concerned because his provider told him he has a heart murmur. The nurse should explain to the client that a murmur

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient who has been involved in a motor vehicle crash arrives in the emergency department (ED) with cool, clammy skin; tachycardia; and hypotension. Which intervention prescribed by the health care provider should the nurse implement first?

Correct Answer is A

Explanation

A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.)

Correct Answer is ["A","B","C","D","E"]

Explanation

Which of the following is NOT an appropriate indication for the use of dopamine in critical care?

Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires action by the nurse?

Which of the following is an appropriate nursing intervention for a patient with a pulmonary artery catheter?

Mr Jones came to the ER complaining of chest palpitations. He states his heart feels like it is "racing". The nurse found the following rhythm on the monitor. What is the next step would the nurse expect to take first?

A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions?

An older patient with cardiogenic shock is cool and clammy. Hemodynamic monitoring indicates a high systemic vascular resistance (SVR). Which intervention should the nurse anticipate?

An 81-yr-old patient who has been in the intensive care unit (ICU) for a week is now stable and transfer to the progressive care unit is planned. On rounds, the nurse notices that the patient has new onset confusion. What should the nurse plan to do?