A client asks the nurse to describe what causes a murmur. What would be the correct response by the nurse?
"Poor electric impulse conduction through the heart
"Turbulent blood flow through the heart valves"
"Enlargement of the left ventricle."
"Weak contraction of the atria."
"Long-term systemic hypertension."
The Correct Answer is B
A. Poor electrical impulse conduction may lead to arrhythmias but does not cause a murmur.
B. A heart murmur is caused by turbulent blood flow, often through narrowed or leaking valves, creating an abnormal heart sound.
C. Left ventricular enlargement can contribute to other cardiac issues but does not directly cause murmurs.
D. Weak atrial contractions may lead to decreased cardiac output but not necessarily to a murmur.
E. While hypertension can affect the heart, it is not the direct cause of a murmur.
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Correct Answer is C
Explanation
A. Curved prongs fitting the nasal passages correctly is appropriate practice for comfort and effective delivery.
B. Padding pressure areas on the skin is a best practice to prevent skin breakdown and is indicative of proper care.
C. An oxygen flow rate of 10 L/min is excessively high for a nasal cannula, which typically accommodates 1-6 L/min; this indicates a need for further education on proper flow rates.
D. Posting clear no smoking and no open flame signs is essential for safety in oxygen therapy, reflecting good practice.
E. Proper adjustment of cannula tubing under the neck is necessary to ensure a secure fit without causing discomfort.
Correct Answer is B
Explanation
A. Using the incentive spirometer is primarily aimed at preventing respiratory complications, not directly related to DVT prevention.
B. Dangling the legs off the bed promotes blood flow and prepares the client for ambulation, which helps prevent venous stasis and reduces the risk of DVT.
C. Encouraging ambulation is crucial for DVT prevention, but this task typically requires nursing judgment and assessment.
D. Keeping the knees elevated for prolonged periods may increase the risk of venous stasis, potentially contributing to DVT formation.
E. Limiting fluids without a clinical indication can lead to dehydration, which may increase the risk of blood clots.