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 []

Explanation

In respiratory acidosis, there is an accumulation of carbon dioxide (CO2) in the blood due to inadequate ventilation, leading to an increase in the partial pressure of arterial carbon dioxide (PaCO2) and a decrease in pH.

This is often caused by conditions that impair ventilation, such as airway obstruction, respiratory muscle weakness, lung diseases (e.g., chronic obstructive pulmonary disease, pneumonia), or central nervous system depression (e.g., drug overdose, head injury).

Management of respiratory acidosis include bronchodilators, sodium bicarbonate, adequate ventilation, and treatment of underlying causes.

A. Give PRN lorazepam (Ativan) and cancel the transfer. B. Obtain an order for restraints as needed and transfer the patient. C. Notify the health care provider and postpone the transfer. D. Inform the receiving nurse and then transfer the patient.

Correct Answer is C

Explanation

C. This allows for the patient's condition to be re-evaluated, ensuring that they receive the necessary care and attention before being transferred.

A. Benzodiazepines can cause sedation, cognitive impairment, and delirium, which may worsen the patient's condition. Canceling the transfer without addressing the underlying cause of confusion may delay appropriate management.

B. Restraints can increase agitation, anxiety, and risk of injury, and they do not address the underlying cause of confusion. Restraints should only be considered as a last resort if all other measures to ensure patient safety have been exhausted.

D. This option is not appropriate because transferring the patient without addressing the new-onset confusion could compromise patient safety. It's essential to identify and manage the underlying cause of confusion before transferring the patient to another unit.

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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

Correct Answer is []

Explanation

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?

Correct Answer is C

Explanation

A patient admitted with urosepsis and alcohol abuse had three seconds of PVCS and returns to sinus tachycardia. The patient's baseline heart rate ie 116/ min with a temperature of 101.1F, respirations of 22/min and blood pressure is 114/64. What should the nurse anticipate to do first?

Which assessment finding by the nurse caring for a patient receiving mechanical ventilation indicates the need for suctioning?

Which of the following factors can directly affect cardiac output?

A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?

Norepinephrine has been prescribed for a patient who was admitted with dehydration and hypotension. Which data indicate that the nurse should consult with the health care provider before starting the norepinephrine?

Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the patient's caregiver is accurate?

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?