When auscultating the breath sounds of a client with pericarditis, the nurse would expect to find which of the following?

Friction rub

Wheezes

Rales

Rhonchi

Answer and Explanation

The Correct Answer is A

A. A friction rub is the characteristic auscultatory finding in pericarditis. It is a high-pitched, scratchy sound heard best at the left lower sternal border and is caused by the inflamed pericardial layers rubbing against each other.
B. Wheezes are continuous, musical sounds usually associated with airway narrowing, such as in asthma or COPD.
C. Rales (crackles) are heard in conditions like pulmonary edema or pneumonia, not pericarditis.
D. Rhonchi are low-pitched, snoring sounds associated with mucus or obstruction in the larger airways.

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Correct Answer is D

Explanation

A. Ventricular tachycardia is a run of three or more consecutive ventricular beats at a rapid rate, not every other beat.
B. Multifocal premature ventricular contractions (PVCs) arise from different ventricular foci and have different shapes, but this scenario describes uniform shape and consistent pattern.
C. Ventricular couplets are two consecutive PVCs, not a pattern where every other beat is abnormal.
D. Ventricular bigeminy is the correct term for a rhythm in which every other beat is a premature ventricular contraction (PVC). These PVCs typically have no visible P wave and a wide, bizarre QRS complex, matching the description given.

A. Notify the health care provider immediately. B. Document the finding and continue to monitor the patient. C. Prepare the patient for temporary pacemaker insertion. D. Give atropine per agency dysrhythmia protocol.

Correct Answer is B

Explanation

A. Notifying the health care provider immediately is not necessary, as the PR interval is at the upper limit of normal (0.20 seconds) and the client is stable.
B. Document the finding and continue to monitor the patient – A PR interval of 0.20 seconds with a normal heart rate and rhythm does not require intervention; just ongoing observation.
C. Prepare the patient for temporary pacemaker insertion – This is used for serious conduction blocks or symptomatic bradycardia, which are not present here.
D. Give atropine per agency dysrhythmia protocol – Atropine is used for symptomatic bradycardia, which this client does not exhibit.

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When auscultating the breath sounds of a client with pericarditis, the nurse would expect to find which of the following?

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Naxlex Comprehensive Predictor Exams

The nurse notes that a client's cardiac monitor shows that every other beat is earlier than expected, has no visible P wave, and has a QRS complex that is wide and bizarre in shape. How will the nurse document the rhythm?

Correct Answer is D

Explanation

A client has a normal cardiac rhythm and a heart rate of 72 beats/minute. The nurse determines the P-R interval is 0.20 seconds. The most appropriate intervention by the nurse would be to

Correct Answer is B

Explanation

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