A nurse is auscultating a client's heart sounds and hears a third heart sound (S3). Which finding is consistent with the presence of an S3 sound in a client with congestive heart failure?

High-pitched, scratchy sound heard during inhalation

Extra heart sound heard immediately after S1 and S2

Prolonged, whooshing sound heard during systole

Irregular heart rhythm with varying intensity

Answer and Explanation

The Correct Answer is B

A) This choice is incorrect because a high-pitched, scratchy sound heard during inhalation is called a pleural friction rub and is associated with pleuritis or inflammation of the pleura, not congestive heart failure.

B) This choice is correct. An S3 heart sound is an extra heart sound heard immediately after S1 and S2, often described as a "ventricular gallop." It is associated with congestive heart failure and indicates increased fluid volume and strain on the ventricles.

C) This choice is incorrect because a prolonged, whooshing sound heard during systole is a heart murmur, which can be caused by various conditions, but it is not specific to the presence of an S3 sound.

D) This choice is incorrect because an irregular heart rhythm with varying intensity is characteristic of cardiac arrhythmias or irregular heartbeats and is not specific to the presence of an S3 sound.

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Correct Answer is C

Explanation

A) This choice is incorrect because hypokalemia (low potassium levels) is more commonly associated with loop diuretics rather than beta-blockers.

B) This choice is incorrect because while hypotension (low blood pressure) can be a potential adverse effect of beta-blockers, it is not the primary adverse effect to be monitored for.

C) This choice is correct. Bradycardia (slow heart rate) is a common adverse effect of beta-blockers, which work by slowing the heart rate and reducing the force of the heart's contractions. The nurse should monitor the client's heart rate and report any significant changes or symptoms of bradycardia to the healthcare provider.

D) This choice is incorrect because hyperglycemia (high blood glucose levels) is not a common adverse effect of beta-blockers. In fact, beta-blockers can sometimes cause transient hypoglycemia.

A. Monitor blood pressure daily and adjust the dose accordingly. B. Avoid foods high in potassium while on this medication. C. Take the medication with a glass of grapefruit juice. D. Limit fluid intake to prevent fluid overload.

Correct Answer is A

Explanation

A) This choice is correct. ACE inhibitors are used to lower blood pressure and reduce the workload on the heart. The client should monitor their blood pressure regularly and report any significant changes to their healthcare provider. Adjustments to the medication dosage should only be made under the guidance of the healthcare provider.

B) This choice is incorrect because while ACE inhibitors can increase potassium levels, avoiding foods high in potassium is not necessary unless specifically directed by the healthcare provider. The client should follow a balanced diet and inform the healthcare provider of any changes in their dietary habits.

C) This choice is incorrect because ACE inhibitors should not be taken with grapefruit juice. Grapefruit juice can interfere with the metabolism of the medication, leading to increased levels and potential side effects.

D) This choice is incorrect because limiting fluid intake is not specific to the administration of ACE inhibitors. Fluid intake may need to be adjusted based on the client's overall fluid balance and congestive heart failure status, but it is not a direct instruction related to the medication.

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A nurse is auscultating a client's heart sounds and hears a third heart sound (S3). Which finding is consistent with the presence of an S3 sound in a client with congestive heart failure?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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