The nurse auscultates a loud heart murmur while performing a cardiac assessment on a client. The nurse is aware that a heart murmur reflects:

increased fluid in the pericardial sac.

dysfunction of one or more heart valves.

an aneurysm of the descending aorta.

an occlusion of the right coronary artery.

Answer and Explanation

The Correct Answer is B

A. increased fluid in the pericardial sac: While fluid accumulation can affect heart sounds, it typically leads to muffled heart sounds rather than a loud murmur. Increased fluid in the pericardial sac (pericardial effusion) usually does not produce a classic heart murmur.

B. dysfunction of one or more heart valves: This statement is correct. Heart murmurs are often caused by turbulence in blood flow due to the dysfunction of heart valves, such as stenosis (narrowing) or regurgitation (leaking). A loud murmur suggests significant turbulence, which is often indicative of valvular heart disease.

C. an aneurysm of the descending aorta: While an aortic aneurysm can cause other types of heart sounds or signs of cardiovascular compromise, it is not primarily associated with heart murmurs.

D. an occlusion of the right coronary artery: An occlusion may lead to ischemia or myocardial infarction, which can cause changes in heart sounds, but it does not directly cause a heart murmur. Murmurs are more specifically related to blood flow dynamics, particularly involving valves.

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Correct Answer is B

Explanation

A. "will confirm a diagnosis of G6PD anemia": This statement is incorrect. The Schilling test is specifically used to evaluate vitamin B12 absorption and diagnose conditions like pernicious anemia, not G6PD deficiency.

B. "is a 24-hour urine specimen collection test": This statement is accurate. The Schilling test typically involves collecting a 24-hour urine specimen to measure the amount of radioactively labeled vitamin B12 excreted in the urine, which helps determine if the body is absorbing vitamin B12 properly.

C. "involves limiting intake of animal proteins": This statement is misleading. While dietary restrictions may be necessary for certain tests, the Schilling test primarily focuses on the absorption of vitamin B12 and does not require limiting animal protein intake.

D. "entails administration of methylcellulose prior to the test": This statement is incorrect. Methylcellulose is not involved in the Schilling test. The test typically includes administration of oral vitamin B12 with or without intrinsic factor to evaluate absorption.

A. 2 inches 21 gauge B. 1 1/2 inch 27 gauge C. 5/8 inch 25 gauge D. 1/4 inch 19 gauge

Correct Answer is C

Explanation

A. 2 inches 21 gauge: This option is too long and too large in gauge for subcutaneous administration. Typically, a longer needle is not necessary for subcutaneous injections, especially for standard adult adipose tissue.

B. 1 1/2 inch 27 gauge: While this gauge is acceptable, the length is still longer than typically required for subcutaneous injections. A 1 1/2 inch needle is more suited for intramuscular injections.

C. 5/8 inch 25 gauge: This is the most appropriate choice for a subcutaneous injection. A 5/8 inch needle is typically adequate for subcutaneous tissue in adults, and a 25 gauge needle provides a suitable size for comfort while allowing the medication to be administered effectively.

D. 1/4 inch 19 gauge: This option is not suitable for subcutaneous injections. A 1/4 inch length is too short for effective penetration into subcutaneous tissue, and a 19 gauge needle is larger than necessary, which could increase discomfort.

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The nurse auscultates a loud heart murmur while performing a cardiac assessment on a client. The nurse is aware that a heart murmur reflects:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In preparation for a client having a Schilling test the nurse should explain that the test:

Correct Answer is B

Explanation

The nurse calculates that 0.74 mi of filgrastim must be administered to a client subcutaneously. The client weights 165 lbs. What length and gauge of needle is best to administer this medication?

Correct Answer is C

Explanation

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