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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The finding that is the highest priority for the PN to report to the charge nurse is the blood urea nitrogen (BUN) level of 75 mg/dL or 12.9 mmol/L. This result indicates an elevated BUN level, which can be indicative of impaired kidney function. In a client receiving chemotherapy, an elevated BUN level may suggest chemotherapy-induced nephrotoxicity or other kidney-related complications. Prompt reporting is crucial to ensure appropriate intervention and management of the client's kidney function.
B. While the platelet count of 135,000/mm3 or 135 x 109/L is slightly below the normal reference range, it does not pose an immediate life-threatening risk. However, it should still be monitored and reported to the healthcare team for ongoing assessment and evaluation.
C. Decreased deep tendon reflexes may be an expected side effect of certain chemotherapy medications or a manifestation of neurotoxicity. While this finding should be documented and monitored, it is not as urgent as the elevated BUN level.
D. Periodic nausea and vomiting are common side effects of chemotherapy, but they may also be indicative of other underlying issues such as dehydration, electrolyte imbalances, or gastrointestinal complications. While this finding should be addressed and managed, it is not the highest priority compared to the elevated BUN level.
Correct Answer is B
Explanation
A. Using a cushion when sitting may provide comfort, but it does not directly address the client's elevated blood pressure or changes in mental status related to chronic kidney disease (CKD).
B. Weighing every morning is crucial in managing CKD, particularly with elevated blood pressure, as it helps monitor fluid retention, which can indicate worsening kidney function or fluid overload. This intervention is essential for assessing the client's condition and adjusting treatment as needed.
C. Performing range of motion exercises is important for maintaining mobility, especially in an immobile client; however, it does not directly address the pressing issues of elevated blood pressure and altered mental status.
D. Documenting abdominal girth can be important for assessing fluid retention, but it is less immediate than daily weight monitoring for a client with CKD showing significant symptoms.
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