During a cardiovascular assessment, the nurse auscultates a split S2. What does this finding most likely indicate?

Correct Answer: A

Rationale: The split S2 sound is typically heard during inspiration and is considered a normal finding. It occurs due to a slight delay in the closure of the aortic valve compared to the pulmonic valve. This physiological delay results in the splitting of the S2 heart sound. Aortic stenosis (B), heart failure (C), and pulmonary embolism (D) are associated with different abnormal cardiovascular conditions that would present with other characteristic auscultatory findings, such as murmurs, gallops, or wheezing, respectively.

Correct Answer: A

Rationale: produced as a byproduct of metabolic activities that generate energy for cellular functions, is correct as metabolism (e.g., in liver, muscles) generates heat via ATP production. No other choices are provided, but this aligns with physiology: cellular respiration converts nutrients into energy, releasing heat to maintain 98.6°F. Shivering or exercise boosts this, but basal metabolism is primary. The hypothalamus regulates this heat against losses (e.g., radiation). Unlike external sources, internal metabolic heat is constant, supporting homeostasis. Nursing recognizes this in fever (increased metabolism) or hypothermia (decreased). Thus, A is accurate, reflecting the bodys fundamental heat production mechanism.

Correct Answer: A

Rationale: The tympanic method measures temperature via the ear canal, requiring specific precautions. An earache contraindicates this method because pain suggests inflammation or infection, risking inaccurate readings or discomfort. Earwax can affect accuracy but isn't an absolute contraindication if minimal. An ear infection is similar to an earache but less specific here; A encompasses it. Taking the temperature in the downward ear after sleeping may skew results due to trapped heat. Choice A is correct as it prioritizes patient comfort and accuracy, reflecting clinical guidelines to avoid tympanic measurement in painful or inflamed ears, ensuring reliable vital sign assessment.

Correct Answer: C

Rationale: Hyperthermia is an uncontrolled rise in body temperature when heat production exceeds dissipation , often from external factors or exertion, not set-point shifts. A downward set-point shift isn't hyperthermia. An upward shift defines fever, not hyperthermia. Reduced mechanisms may contribute but isn't the definition. Choice C is correct, distinguishing hyperthermia from fever per nursing pathophysiology, critical for appropriate interventions.

Correct Answer: B

Rationale: A postoperative BP drop from 128/70 to 100/60 indicates potential shock or bleeding, a priority. Smoking or pain with stable BP is less urgent. Hypothermia needs attention but lacks acuity data. Choice B is correct, per triage urgency in surgical care.