The practical nurse (PN) is auscultating a client's heart sounds. Which abnormal heart sound should the PN report to the charge nurse? (Please listen to the audio file to select the option that applies.)
S4.
S2.
S1.
S3.
Correct Answer : A,D
S3 is an extra heart sound that occurs during diastole (the filling phase of the cardiac cycle). It is commonly associated with conditions such as heart failure and volume overload. S3 is often described as a low-frequency, dull, and distant sound heard after S2 (the second heart sound).
B, C- S1, and S2 are the normal heart sounds that are typically heard in all individuals. S1 is the first heart sound, heard as "lub," and is caused by the closure of the mitral and tricuspid valves. S2 is the second heart sound, heard as "dub," and is caused by the closure of the aortic and pulmonic valves. These sounds are normal and expected.
S4 is another abnormal heart sound, which occurs during late diastole and is associated with conditions such as ventricular hypertrophy and reduced ventricular compliance.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This is the priority action by the practical nurse (PN) because it can help identify and prevent a potential adverse reaction to the medication. A client who is reaching saturation with medication means that the client has reached the maximum level of medication in the blood that can produce the desired therapeutic effect. However, this also means that the client is at a higher risk of developing toxicity or side effects from the medication.
The PN should report the findings of muscle soreness, fatigue, and warm skin to the charge nurse, as these may indicate signs of inflammation, infection, or allergic reaction to the medication. The PN should also monitor the client's vital signs, oxygen saturation, and laboratory values, and document the findings. The charge nurse should notify the health care provider and adjust the medication dosage or regimen as ordered.
Correct Answer is C
Explanation
When admitting a client with complications of left-sided heart failure, the practical nurse (PN) should prioritize assessing the client's bilateral lung sounds. Left-sided heart failure can result in the accumulation of fluid in the lungs, leading to pulmonary congestion and impaired gas exchange. By auscultating the client's lung sounds, the PN can assess for the presence of crackles, wheezes, or diminished breath sounds, which are indicative of pulmonary congestion and fluid accumulation. This assessment helps to identify the severity of the client's condition and guides further interventions and treatment.
While assessing heart sounds (option a) is important in evaluating cardiac function, assessing lung sounds takes priority as pulmonary congestion is a common manifestation of left-sided heart failure. Chest pain (option b) is a significant symptom that should be assessed promptly, but in this scenario, the focus is on assessing for signs of pulmonary congestion and impaired gas exchange. Assessing the client's mood and affect (option d) is important for a comprehensive assessment, but it is not the priority when the client is admitted with complications of left-sided heart failure.
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