A nurse is performing a cardiac assessment on a client and auscultates an S3 sound. The nurse should recognize that this sound represents which of the following heart conditions?
Closure of pulmonic valve
Closure of the mitral valve
Ventricular gallop
Atrial gallop
The Correct Answer is C
Ventricular gallop is another name for the S3 sound, which is a low-pitched sound heard at the end of diastole, just after the S2 sound. It is caused by the rapid filling of the ventricles and the vibration of the ventricular walls.
Closure of the pulmonic valve is one of the components of the S2 sound, which is a high-pitched sound heard at the end of the systole, just before the S1 sound. It is caused by the closure of the semilunar valves (pulmonic and aortic).
Closure of the mitral valve is one of the components of the S1 sound, which is a high-pitched sound heard at the beginning of systole, just after the S2 sound. It is caused by the closure of the atrioventricular valves (mitral and tricuspid).
d. Atrial gallop is another name for the S4 sound, which is a low-pitched sound heard at the end of diastole, just before the S1 sound. It is caused by atrial contraction and increased resistance to ventricular filling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A headache is a common and expected adverse effect of nitroglycerin, due to its vasodilating action. The client can take an over-the-counter analgesic to relieve the headache, unless contraindicated.
"A headache is an indication of an allergy to the medication." is not correct, as a headache is not a sign of an allergic reaction to nitroglycerin. An allergic reaction would manifest as rash, itching, swelling, or difficulty breathing.
"A headache indicates tolerance to the medication." is not accurate, as a headache does not indicate tolerance to nitroglycerin. Tolerance would manifest as reduced or absent relief from anginal pain.
"A headache is likely due to the anxiety about the chest pain." is not plausible, as a headache is not likely due to the anxiety about the chest pain. Anxiety would manifest as nervousness, restlessness, palpitations, or sweating.
Correct Answer is B
Explanation
The priority nursing action is to notify the provider of the client's allergy because shellfish allergy may indicate an allergy to iodine, which is commonly used as a contrast dye in cardiac catheterization. This could cause a severe allergic reaction or anaphylaxis during the procedure, which could be life-threatening. The provider may need to order a different type of contrast dye or premedicate the client with antihistamines or steroids to prevent an allergic reaction.
a. Ask the client if any other foods cause such a reaction is wrong because it is not the priority action and it does not address the potential risk of iodine allergy.
c. Notify the dietary department of the client's allergy is wrong because it is not relevant to the cardiac catheterization and it does not prevent an allergic reaction during the procedure.
d. Atach a wrist band indicating the client's allergy is wrong because it is not sufficient to alert the provider or the catheterization team of the client's allergy and it does not prevent an allergic reaction during the procedure.
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