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 C
Explanation
- Medication administration is a process that involves prescribing, dispensing, and giving medications to patients. It is a critical and complex task that requires accuracy, safety, and adherence to the rights of medication administration, such as the right patient, right drug, right dose, right route, right time, right documentation, and right response.
- When a male client tells the practical nurse (PN) that the pill he has been taking at home is a different color and size than the one the PN is trying to give him now, this may indicate a potential medication error
or discrepancy. A medication error is any preventable event that may cause or lead to inappropriate medication use or patient harm. A medication discrepancy is any difference between the current and previous medication regimens of a patient.
- The PN should respond to the client's concern by telling him that the PN will verify that the dispensed medication is a valid prescription. This means that the PN will check the medication label, the medication order, and the medication administration record (MAR) to confirm that the medication given to the client matches the one prescribed by the healthcare provider. The PN will also compare the dispensed medication with a drug reference guide or a picture of the medication to ensure that it is the correct drug and dosage form. The PN will also report any suspected errors or discrepancies to the healthcare provider or the pharmacy for clarification or correction.
- Options A, B, and D are incorrect answers, as they do not reflect the appropriate or responsible actions for the PN to take when faced with a possible medication error or discrepancy.
Correct Answer is D
Explanation
When a client's family member expresses concerns about the care provided, it is essential for the nurse to gather more information and understand the specific issues raised. By asking for a description of what happened during the night, the nurse can obtain details about the perceived inadequate care. This allows the nurse to gather accurate information, assess the situation, and address any legitimate concerns.
A. Explaining that all staff are doing their best may not address the specific issues raised by the daughter and may not provide a satisfactory resolution to her concerns.
B. Telling the daughter to talk with the unit's nurse manager can be an appropriate step, but it should come after gathering information about the situation. The nurse needs to have a clear understanding of what happened before involving the nurse manager.
C. Reassuring the daughter that the mother will get better care may not address her concerns and may not provide a solution to the perceived problem. It is important to gather more information before offering reassurance or making promises.
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