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. Liver: Liver is high in cholesterol and should be avoided by clients on a low-cholesterol diet. This is not a suitable choice for the client.

B. Beans: Beans are a high-fiber, plant-based protein source that is low in cholesterol. This is a good choice for a low-cholesterol diet.

C. Eggs: Eggs contain cholesterol, particularly in the yolk. While one egg a day may be acceptable for some individuals, this is generally a food that should be limited on a low-cholesterol diet.

D. Milk: Depending on the fat content, milk can be high in cholesterol. Clients should opt for skim or low-fat milk to reduce cholesterol intake. Full-fat milk is not ideal for a low-cholesterol diet.

A. "I will sit on the side of the bed before I stand up." B. "I should weigh myself on the same day once a week." C. "I should expect to develop a slight cough while taking this medication." D. "I will not take my medicine if my heart rate is greater than 70/min."

Correct Answer is A

Explanation

A. "I will sit on the side of the bed before I stand up." Propranolol can cause orthostatic hypotension, so the client should sit on the edge of the bed before standing to avoid dizziness or falls. This statement shows correct understanding.

B. "I should weigh myself on the same day once a week." Clients taking propranolol, especially if they have heart failure, should weigh themselves daily to monitor for fluid retention. Weekly weighing is insufficient for identifying early signs of worsening heart failure.

C. "I should expect to develop a slight cough while taking this medication." A cough is more commonly associated with ACE inhibitors (such as lisinopril) rather than beta-blockers like propranolol. This statement indicates a misunderstanding.

D. "I will not take my medicine if my heart rate is greater than 70/min." Beta-blockers like propranolol are typically withheld if the heart rate is below 60 beats per minute, not when it is greater than 70. This statement shows a misunderstanding of when to hold the medication.

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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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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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