Cardiac Disorders NCLEX (100% Accurate Answers)

The nurse is assessing a pt w/ chronic heart failure. Which abnormal chest sound would the nurse most likely auscultate? 1. expiratory wheezes 2. friction rub 3. harsh vesicular 4. crackles correct answers Answer: 4 Rationale 1, 2, 3: Expiratory wheezes, friction rub, & harsh vesicular sounds are not associated w/ chronic heart failure. Rationale 4: Fluid accumulates in the alveolar spaces w/ left-sided heart failure. This fluid causes the sound of crackles at the end of inspiration. When caring for a chronic heart failure pt w/ left-sided failure, the nurse would most likely note the following statement in the physician's written report following cardiac catheterization? 1. "Pressures in the left ventricle & atrium are increased." 2. "Pressures in the left ventricle & atrium are decreased." 3. "Pressures in the right ventricle & atrium match the ventricle pressures." 4. "Pressures in the right ventricle reflect functioning of all heart chambers." correct answers Answer: 1 Rationale 1: As the heart loses its ability to eject blood effectively from the left ventricle upon contraction, blood is retained in the left ventricle after systole & the chamber pressure rises due to the added blood volume. Rationale 2: As the heart loses its ability to eject blood effectively from the left ventricle upon contraction, blood is retained in the left ventricle after systole & the chamber pressure rises due to the added blood volume. Rationale 3: This pt is in left-sided heart failure, so pressure is higher in the left side of the heart, not the right side. Rationale 4: This pt is in left-sided heart failure, so pressure is higher in the left side of the heart, not the right side. A nurse caring for a pt w/ heart failure would expect to find which of the following during assessment of the pt? 1. S1, S2 & flat neck veins 2. S3 & distended neck veins 3. S2 is heard the loudest & followed by S1 4. S4 & flat neck veins correct answers Answer: 2 Rationale 1: S1 & S2 are normal heart sounds; flat neck veins are considered a normal finding. Rationale 2: The abnormal S3 sound is reflective of the heart's attempts to fill an already distended ventricle & the neck veins distend because of the increased venous pressure. Rationale 3: S1 & S2 sounds may be diminished in the heart failure pt & not vary in intensity. Rationale 4: S4 (gallop) may be present but neck veins would be distended. When obtaining the health history of a pt who is being assessed for possible congestive heart failure, it is significant when the pt says which of the following? 1. "I break out in a cold sweat when I eat a large meal."