A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds?

A friction rub

A split second heart sound S₂

The third heart sound (S3)

The fourth heart sound (S4)

Answer and Explanation

The Correct Answer is D

A. A friction rub: A friction rub is a sound caused by the rubbing of inflamed pericardial layers and is not classified as a heart sound like S1 or S2. It is unrelated to the sequence of heart sounds.

B. A split second heart sound S₂: A split S₂ occurs during the closure of the aortic and pulmonary valves and is heard after S1, not before.

C. The third heart sound (S3): S3, or the ventricular gallop, occurs shortly after S2 during early diastole and indicates rapid ventricular filling. It is not heard before S1.

D. The fourth heart sound (S4): S4, known as the "atrial gallop," occurs just before S1 during atrial contraction. It is associated with a stiff or hypertrophied ventricle and is often indicative of underlying heart disease, especially in older adults.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Excessive thrombosis and bleeding

Disseminated Intravascular Coagulation (DIC) is a complex and serious condition characterized by widespread activation of the coagulation cascade, leading to both excessive clot formation (thrombosis) and simultaneous consumption of clotting factors and platelets, resulting in bleeding. DIC can occur as a secondary complication to various conditions such as sepsis, trauma, or obstetric complications.

B. Increased clotting factors: In DIC, there is consumption and depletion of clotting factors, not an increase.

C. Progressive increase in platelet production: Platelet production does not increase in DIC; instead, there is consumption and decreased platelet count.

D. Immediate sodium and fluid retention: DIC is not associated with immediate sodium and fluid retention; instead, it is characterized by fluid loss due to bleeding.

A. Troponin is a lipid whose levels reflect the risk for coronary artery disease. B. Troponin is an enzyme that indicates damage to brain, heart, and skeletal muscle tissues. C. Troponin is a protein that helps transport oxygen throughout the body. D. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart

Correct Answer is D

Explanation

A. Troponin is a lipid whose levels reflect the risk for coronary artery disease: This statement is incorrect. Troponin is not a lipid, and its levels do not reflect the risk for coronary artery disease. Troponin is a protein associated with muscle tissue.

B. Troponin is an enzyme that indicates damage to brain, heart, and skeletal muscle tissues: While troponin indicates damage to muscle tissues, it is specifically associated with cardiac muscle, not brain or skeletal muscle tissues.

C. Troponin is a protein that helps transport oxygen throughout the body: This statement is incorrect. While proteins in the blood may contribute to oxygen transport, troponin's primary role is in muscle contraction, particularly in the heart.

D. Troponin is a heart muscle protein that appears in the bloodstream when there is damage to the heart: This is the correct answer. Troponin is a protein found in cardiac muscle cells, and when there is damage to the heart, such as during a myocardial infarction, troponin is released into the bloodstream. Elevated troponin levels in the blood are indicative of myocardial injury or infarction.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is auscultating a client's heart sounds and hears an extra heart sound before what should be considered the first heart sound S1. The nurse should document this finding as which of the following heart sounds?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has disseminated intravascular coagulation (DIC). Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

A nurse is teaching a client who has tuberculosis and is to start combination drug therapy. Which of the following medications should the nurse plan to administer? (Select all that apply.)

A nurse is reviewing the laboratory findings for a client who has idiopathic thrombocytopenic purpura (ITP). Which of the following findings should the nurse expect to be decreased?

A nurse is reviewing blood pressure classifications with a group of nurses at an in-service meeting. Which of the following should the nurse include as a risk factor for the development of hypertension?

A nurse is reviewing a client's laboratory results and finds the hemoglobin is 10 g/dL. and the hematocrit is 30%. The nurse recognizes that the client is at risk for which of the following?

A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should the nurse take?

A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority?

A nurse is providing instructions to a client who has a new prescription for sublingual nitroglycerin (Nitrostat) to treat angina pectoris. Which of the following instructions should the nurse include?

A nurse is caring for an older adult client who has left-sided heart failure. Which of the following assessment findings should the nurse expect?