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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Correct Answer is A

Explanation

A. Count the apical pulsations for a full minute. The apical pulse should be counted for a full minute to ensure accuracy, especially in clients taking cardiovascular medications, as these may affect heart rhythm and rate.

B. Place the stethoscope just under the mid-clavicular area of the left chest. The apical pulse is typically located at the fifth intercostal space at the midclavicular line, not directly under the clavicle.

C. Press the stethoscope firmly against the client's skin. While the stethoscope needs to be in full contact with the skin, excessive pressure is not necessary and may distort the sound.

D. Check the apical pulse with a Doppler device. A Doppler is typically used when the pulse is difficult to palpate or auscultate, not as a first-line method for checking the apical pulse.

A. Check the client's blood pressure. B. Check the client's IV catheter insertion site. C. Check the level of the client's pain. D. Check the client's bowel sounds.

Correct Answer is C

Explanation

A. Check the client's blood pressure. While it is important to monitor vital signs after surgery, checking blood pressure is not the first action unless the client is showing signs of instability.

B. Check the client's IV catheter insertion site. Assessing the IV site is important for identifying complications such as infiltration or phlebitis, but this is not the priority.

C. Check the level of the client's pain. Pain assessment is the priority because unmanaged pain can affect recovery and indicate complications such as bleeding or infection. Managing pain is crucial in the postoperative period.

D. Check the client's bowel sounds. Assessing bowel sounds is important following abdominal surgery, but it is not the first priority compared to pain assessment.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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