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 B

Explanation

A. A 3-year-old with fever, rash, and sore throat should be evaluated promptly, but these symptoms do not necessarily indicate an immediate life-threatening emergency.
B. A 45-year-old man with chest pain and diaphoresis for 1 hour is the priority because these are classic symptoms of acute coronary syndrome (ACS) or myocardial infarction (MI). Immediate emergency assessment and intervention are required.
C. A 14-year-old girl crying about a possible pregnancy needs emotional support and counseling but does not require immediate emergency intervention.
D. A 20-year-old man with a 3-inch shallow laceration on his leg needs wound care, but his condition is not life-threatening and does not require emergency assessment.

A. Right upper quadrant B. Left upper quadrant C. Left lower quadrant D. Right lower quadrant

Correct Answer is C

Explanation

A. Pressing in the right upper quadrant is not appropriate for a referred rebound tenderness test, which is used to assess peritoneal irritation, commonly from appendicitis.
B. Pressing in the left upper quadrant is not useful in diagnosing appendicitis or conditions that cause referred pain to the right lower quadrant.
C. Pressing in the left lower quadrant is correct when performing Rovsing’s sign, a test for referred rebound tenderness. If the client experiences pain in the right lower quadrant when the left lower quadrant is pressed, it suggests peritoneal irritation, often due to appendicitis.
D. Pressing in the right lower quadrant would directly elicit tenderness in appendicitis but does not test for referred rebound tenderness.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is working in an ambulatory care clinic that is located in a busy, inner-city neighborhood. Which client would the nurse determine to be in most need of an emergency assessment?

Correct Answer is B

Explanation

A client is brought to the acute hospital setting with severe abdominal pain. The nurse is evaluating a new graduate's ability to perform a referred rebound tenderness test. The nurse identifies correct technique when the new graduate is observed pressing deeply at which abdominal location?

Correct Answer is C

Explanation

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