A nurse is collecting data about a client's cardiac functioning. The nurse auscultates an S3 sound. Which of the following causes should the nurse suspect?

Atrial gallop

Ventricular gallop

Closing of semilunar valves

Closing of the atrioventricular valves

Answer and Explanation

The Correct Answer is B

A. Atrial gallop: An atrial gallop is associated with the S4 heart sound, which occurs before the S1 sound due to the atrial contraction.

B. Ventricular gallop: An S3 heart sound is known as a ventricular gallop and is often a sign of heart failure or fluid overload. It occurs during early diastole when the ventricle fills rapidly.

C. Closing of semilunar valves: The closing of the semilunar valves (aortic and pulmonary) produces the S2 heart sound, not the S3 sound.

D. Closing of the atrioventricular valves: The closing of the atrioventricular valves (mitral and tricuspid) produces the S1 heart sound, not the S3 sound.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Check pedal pulses every 15 min. Checking pedal pulses every 15 minutes is essential to monitor for adequate blood flow to the extremity and to detect any signs of arterial obstruction or complications at the catheter insertion site.

B. Keep the client in high-Fowler's position for 6 hr. The client should remain flat or in a low-Fowler's position to reduce the risk of bleeding at the femoral artery access site. High-Fowler's position is contraindicated.

C. Remind the client not to turn from side to side. Clients may be allowed to turn gently, but they should avoid putting pressure on the insertion site. Complete immobility is unnecessary.

D. Perform passive range-of-motion for the affected extremity. Passive range of motion is not appropriate in the immediate post-procedure period, as the extremity should remain still to prevent bleeding.

A. "The client may benefit from a neurology consult." B. "The client is disoriented and pupils are slow to respond to light." C. "The client has developed drooping facial features." D. "The client has a history of hypertension."

Correct Answer is D

Explanation

A. "The client may benefit from a neurology consult." This statement is more appropriate for the recommendation component of SBAR. The background should focus on what has already occurred or is known, not what the nurse thinks should be done next.

B. "The client is disoriented and pupils are slow to respond to light." This would be part of the assessment component of SBAR, which describes the nurse's evaluation of the current condition.

C. "The client has developed drooping facial features." This statement can be included in theSituationcomponent because it describes the immediate concern that prompted the communication.

D. "The client has a history of hypertension." This statement is suitable for theBackgroundcomponent. It provides relevant medical history that helps the provider understand the context of the current situation.

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A nurse is collecting data about a client's cardiac functioning. The nurse auscultates an S3 sound. Which of the following causes should the nurse suspect?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client immediately following a cardiac catheterization with a femoral artery approach. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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