When performing a cardiovascular assessment, what would the nurse understand about an S3 heart sound? Select all that apply
Can be caused by a poorly compliant (stiff) ventricle
Can occur with congestive heart failure
Heard just after S1
Always pathologic
Correct Answer : A,B,E
A. An S3 is often associated with a stiff or poorly compliant ventricle.
B. An S3 heart sound can be an indication of congestive heart failure in adults, as it reflects increased fluid volume and pressure in the ventricles.
C. S3 is heard just after S2, not S1.
D. The S3 heart sound is not always pathologic. It is often benign in children, adolescents, and young adults, where it may occur due to a rapid filling phase of the ventricles.
E. In adolescents and younger individuals, an S3 heart sound is usually considered a normal finding.
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Correct Answer is A
Explanation
A. Suctioning the tracheostomy is the priority action to clear secretions, which is likely the cause of the noisy, bubbly respirations. This can help the client breathe more easily.
B. Changing the tracheostomy tube is only necessary if the tube is obstructed or malfunctioning, and suctioning is generally the first step.
C. Notifying the healthcare provider may be needed if suctioning is ineffective or if complications persist, but immediate intervention is required.
D. Changing the tracheostomy dressing does not address the respiratory noise or potential secretion buildup.
E. A head-to-toe assessment may be needed, but the immediate concern is clearing the airway obstruction.
Correct Answer is ["A","B","E"]
Explanation
A. Immobility is a significant risk factor for venous thromboembolism (VTE) since prolonged inactivity can lead to stasis of blood flow, increasing clot formation risk.
B. Smoking contributes to hypercoagulability and vascular damage, both of which elevate the risk of clot formation in veins.
C. A history of stomach ulcers is not directly associated with an increased risk of blood clots; rather, it pertains more to gastrointestinal health.
D. Overhydration generally does not increase the risk of blood clots; rather, maintaining adequate hydration is important for circulation.
E. Taking birth control pills can increase the risk of blood clots due to hormonal changes that promote hypercoagulability.