A nursing student is preforming a head-to-toe assessment on his patient with a history of mitral regurgitation. Instead of hearing normal heart sounds the student hears a murmur.
Which of the following best describes the sound of a heart murmur?
Lub-dub sounds
Gentle blowing or swooshing noise
Scratchy, leathery heart noise
Abrupt, high-pitched snapping noise
The Correct Answer is B
A. Lub-dub sounds:
This describes the normal heart sounds, with the "lub" representing the closing of the mitral and tricuspid valves (S1) and the "dub" representing the closing of the aortic and pulmonic valves (S2). This is the typical and expected sound of a healthy heart.
B. Gentle blowing or swooshing noise:
This describes the characteristic sound of a heart murmur. Murmurs are abnormal sounds caused by turbulent blood flow, and they are often described as a gentle blowing or swooshing noise heard between the normal heart sounds.
C. Scratchy, leathery heart noise:
This description is not typical for heart sounds or murmurs. Heart sounds are usually described in terms of tones, clicks, or swooshing rather than scratchy or leathery.
D. Abrupt, high-pitched snapping noise:
This description is not typical for heart sounds or murmurs. Heart murmurs are generally characterized by a more continuous, blowing, or swooshing quality, rather than abrupt, high-pitched snapping noises.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["20"]
Explanation
To administer the ordered dose of furosemide (Lasix) 20mg, you need to calculate the amount of mL required from the available solution. The available solution has a concentration of 2 mg/2 mL, which means that for every 2 mL of solution, there are 2 mg of furosemide. To find the amount of mL needed to deliver 20 mg of furosemide, you can use the following formula:
mL = (ordered dose / available dose) x available volume
Plugging in the values, we get:
mL = (20 mg / 2 mg) x 2 mL
mL = 10 x 2 mL
mL = 20 mL
Therefore, you need to administer 20 mL of the available solution to give the patient 20 mg of furosemide.
Correct Answer is D
Explanation
A. The client attempted to climb over the side rails and fell:
This statement includes an interpretation of the client's actions. It's important to focus on factual information without making assumptions about the client's intentions or actions.
B. The client was restless and trying to get out of bed all evening:
Describing the client as restless and trying to get out of bed is a subjective interpretation of the client's behavior. Factual and objective observations are preferred when documenting incidents.
C. The presence of a bed alarm could have prevented the client from falling:
This statement includes an interpretation and a suggestion for prevention. While prevention strategies are important to consider, an incident report should primarily focus on describing what actually occurred rather than suggesting what could have prevented it.
D. The client was lying on the floor next to his bed:
This statement provides a clear and objective description of the situation without making assumptions or interpretations. It is important to document the actual events and the client's current condition.
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