While auscultating a client's heart sounds, the nurse hears turbulence between S1 and S2. The nurse should document this finding as which of the following?

A systolic murmur

A third heart sound (S3)

A fourth heart sound (S4)

An expected heart sound

Answer and Explanation

The Correct Answer is A

A. A systolic murmur: A murmur heard between S1 and S2 occurs during systole, which is why it is classified as a systolic murmur. Systolic murmurs are often due to valve abnormalities like aortic stenosis or mitral regurgitation.

B. A third heart sound (S3): The S3 sound occurs after S2, not between S1 and S2. It is associated with rapid ventricular filling and may indicate heart failure.

C. A fourth heart sound (S4): The S4 sound occurs before S1, not between S1 and S2. It is associated with a stiff or hypertrophic ventricle.

D. An expected heart sound: A murmur is not considered an expected heart sound; it is typically abnormal and requires further investigation.

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Correct Answer is B

Explanation

A. Reassuring the partner of a client who sustained a closed head injury: While providing emotional support to family members is important, this is not the first priority. The immediate concern should be a potential physical complication in a client.

B. Collecting data from a client who reports unilateral calf pain when ambulating: Unilateral calf pain can indicate deep vein thrombosis (DVT), which can lead to a pulmonary embolism if left untreated. This is the most urgent situation and requires immediate assessment.

C. Taking a telephone prescription for a client who is to be transferred from PACU: While transferring a client requires coordination, it is not as urgent as assessing for potential life-threatening complications, such as DVT.

D. Reinforcing a client's dressing on an above-the-knee amputation surgical site: While it is important to manage the surgical site, the client with potential DVT requires more immediate attention due to the risk of pulmonary embolism.

A. Hypertension stage 2 B. Elevated or Prehypertension C. Hypertension stage 1 D. Within the expected reference range

Correct Answer is B

Explanation

A. Hypertension stage 2: Hypertension stage 2 is defined as a systolic blood pressure ≥140 mm Hg or diastolic ≥90 mm Hg. The client’s reading of 124/74 mm Hg does not fall into this category.

B. Elevated or Prehypertension: A systolic blood pressure between 120-129 mm Hg and a diastolic <80 mm Hg is classified as elevated or prehypertension. The client’s systolic BP of 124 mm Hg places him in this category.

C. Hypertension stage 1: Hypertension stage 1 is defined as a systolic BP between 130-139 mm Hg or diastolic BP between 80-89 mm Hg. The client’s BP of 124/74 mm Hg does not meet this criterion.

D. Within the expected reference range: The normal range for blood pressure is less than 120/80 mm Hg. The client’s BP of 124/74 mm Hg is slightly elevated and does not fall within the expected reference range.

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While auscultating a client's heart sounds, the nurse hears turbulence between S1 and S2. The nurse should document this finding as which of the following?

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Naxlex Comprehensive Predictor Exams

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