Nokea
The nurse is caring for a client in the cardiac unit who has a systolic murmur. Which assessment finding would the nurse expect when auscultating this client's heart sounds?
- A. The murmur can be heard between S3 and S4.
- B. The murmur can be heard between S4 and S1.
- C. The murmur can be heard between S2 and S1.
- D. The murmur can be heard between S1 and S2.
Correct Answer: D
Rationale: Systolic murmurs occur during systole, between S1 and S2 (D). Other options (A, B, C) do not align with cardiac cycle timing.
You may also like to solve these questions
The nurse is caring for a client with veno-occlusive disease. Which manifestations of this condition would the nurse expect to find? Select all that apply.
- A. jaundice
- B. weight loss
- C. weight gain
- D. right lower quadrant pain
- E. enlargement of the spleen
- F. right upper quadrant pain
Correct Answer: A,C,F
Rationale: Veno-occlusive disease causes jaundice (A), weight gain from ascites (C), and right upper quadrant pain (F) due to liver involvement. Weight loss (B), right lower quadrant pain (D), and splenomegaly (E) are less common.
A nurse is employed on an oncology unit. A 62-year-old client is admitted for surgical treatment of a meningioma. The nurse would anticipate modifying the environment for which symptom?
- A. difficulty swallowing
- B. seizures
- C. poor concentration
- D. impaired mobility
Correct Answer: B
Rationale: Meningiomas commonly cause seizures (B), requiring environmental modifications like padded rails. Swallowing (A), concentration (C), and mobility (D) are less typical.
The nurse is caring for a client with a T-tube following a cholecystectomy. Which statement is correct regarding management of these tubes? Select all that apply.
- A. keep the drainage system at the level of the heart
- B. report foul odor and purulent drainage to the health care provider
- C. remove the tube when drainage slows to less than 50 mL every 8 hours
- D. do not clamp or irrigate the T-tube without orders from the health care provider
- E. clamp the tube before meals and observe the client for abdominal distention or discomfort
Correct Answer: B,D,E
Rationale: Report foul odor/purulent drainage (B), avoid clamping/irrigation without orders (D), and clamp before meals to assess tolerance (E) are correct. Drainage system should be below the incision (A), and removal (C) is physician-ordered.
The nurse is caring for a client who has been diagnosed with pulseless electrical activity (PEA). Following effective CPR and administration of epinephrine, which is the next priority nursing action?
- A. check for a pulse
- B. insert a urinary catheter
- C. prepare to shock the client
- D. administer a bolus of sodium bicarbonate
Correct Answer: A
Rationale: After CPR and epinephrine for PEA, checking for a pulse (A) assesses return of circulation. Shocking (C) is not indicated for PEA, and catheter insertion (B) or bicarbonate (D) are not priorities.
The nurse is performing discharge teaching to a client diagnosed with chronic pancreatitis. Which statement by the client indicates an understanding of home management of the condition? Select all that apply.
- A. I should avoid large, heavy meals.
- B. I can have an occasional glass of red wine.
- C. I can resume my daily jogging once I get home.
- D. I should avoid smoking and caffeinated beverages.
- E. I should add extra spices to my food to make it taste better.
Correct Answer: A,D
Rationale: Avoiding large meals (A) and smoking/caffeine (D) reduces pancreatic stress. Alcohol (B) worsens pancreatitis, jogging (C) depends on condition, and spices (E) may irritate.