An unexpected finding after a cardiac assessment is:

A. A pulse rate of 72 beats per minute
B. Jugular vein pulsation with the client supine
C. PMI found at the midclavicular line
D. A sustained swishing sound during systole or diastole


D
D. Murmurs are sustained swishing or blowing sounds heard at the beginning, middle, or end of systole or diastole. They are caused by increased blood flow through a normal valve, forward flow through a stenotic valve or into a dilated vessel or chamber, or backward flow through a valve that fails to close.
A. Expected outcomes following completion of procedure: Heart rate is between 60 and 100 beats per minute (adolescent through adult) and without extra sounds or murmurs.
B. Expected outcomes following completion of procedure: Jugular veins distend when client lies supine and flatten when client is in sitting position
C. Expected outcomes following completion of procedure: PMI is palpable at fifth intercostal space at left midclavicular line in adult.

Nursing

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Nursing