A nurse experiences difficulty auscultating the heart sounds of a client. What should the nurse do to assure they are able to auscultate the heart sounds?

Place the diaphragm against the client's clothing and angle biannuals toward nose.

Ensure that the ear pieces are loose and comfortable in ears.

Ask the client to hold their breath during auscultation.

Eliminate distracting noises from the environment and ensure a snug fit with the ear pieces.

Answer and Explanation

The Correct Answer is D

A. Placing the diaphragm against clothing can interfere with sound transmission. The stethoscope should be placed directly on the skin.
B. Earpieces should fit snugly in the ears to optimize sound conduction, rather than being loose.
C. Asking the client to hold their breath is not a standard technique for improving heart sound auscultation; it is more useful for breath sounds or murmurs.
D. "Eliminate distracting noises from the environment and ensure a snug fit with the ear pieces" is correct because background noise can interfere with auscultation, and a proper fit enhances sound transmission.

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Correct Answer is C

Explanation

A. Wearing gloves before touching the client is not necessary unless the nurse anticipates contact with bodily fluids, non-intact skin, or mucous membranes.
B. Using a separate, disposable blood pressure cuff is an example of transmission-based precautions, not standard precautions, unless the client has an infection requiring contact precautions.
C. Wearing gloves to palpate the tongue and buccal membranes is correct because standard precautions require gloves when there is potential contact with mucous membranes, which can expose the nurse to infectious agents.
D. Wearing a gown, gloves, and mask is unnecessary unless the client has an infection that requires additional precautions beyond standard precautions.

A. Thinning of the vertebral discs leads to weight loss. B. An increase in lean body mass leads to weight gain. C. Spinal kyphosis contributes to the increase in body weight. D. Loss of muscle tissue contributes to the decrease in weight.

Correct Answer is D

Explanation

A. Thinning of the vertebral discs leads to a decrease in height, not weight.
B. Lean body mass actually decreases with aging, contributing to weight loss rather than gain.
C. Spinal kyphosis affects posture but does not significantly contribute to changes in body weight.
D. Loss of muscle tissue (sarcopenia) is correct because aging leads to a decline in muscle mass, which contributes to weight loss. Additionally, a slower metabolism and reduced physical activity further affect body composition.

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A nurse experiences difficulty auscultating the heart sounds of a client. What should the nurse do to assure they are able to auscultate the heart sounds?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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