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A nurse is auscultating heart sounds and hears a murmur. What should be included in the nurse's documentation? Select all that apply.

Client's blood pressure

Client's weight

Client's respiratory rate

Intensity of the murmur

Location of the murmur

Client's temperature

Timing of the murmur

Client's medication history

Answer and Explanation

Correct Answer : A,D,E,G

A.   Client's blood pressure is relevant as it can help correlate the murmur with potential cardiac conditions.
B.   Client's weight is not directly related to documenting a heart murmur.
C.   Client's respiratory rate is also not relevant to the murmur documentation unless respiratory symptoms are present.
D.   Intensity of the murmur is important to document, as it helps assess the severity.
E.   Location of the murmur is important for identifying which valve or area of the heart is involved.
F.   Client's temperature is not directly related to documenting a heart murmur.
G.   Timing of the murmur helps in identifying whether it occurs during systole or diastole, aiding in diagnosis.

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Correct Answer is D

Explanation

A. Cervical nodes drain the head and neck area, not typically the forearm or hand.
B. Epitrochlear nodes are found near the elbow and are responsible for draining the arm. The nurse would assess these nodes if the infection is in the arm or hand.
C. Inguinal nodes drain the lower extremities and groin area, not the upper extremities.
D. Axillary nodes drain the upper limbs, including the forearm and hand, and are likely to be swollen if there is an infection in the upper extremities.

A. Resonance B. Tactile fremitus C. Bronchovesicular sounds. D. Rhonchi E. Crackles

Correct Answer is ["A","B","C"]

Explanation

A. Resonance is a normal percussion sound heard over healthy lung tissue.
B. Tactile fremitus refers to the palpable vibration felt when a patient speaks and is normal in areas of healthy lung tissue.
C. Bronchovesicular sounds are normal breath sounds heard over the mainstem bronchi and are considered normal.
D. Rhonchi are adventitious sounds (abnormal) heard in conditions like bronchitis and would not be considered normal.
E. Crackles are also abnormal breath sounds often heard in conditions such as pneumonia or heart failure.

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A nurse is auscultating heart sounds and hears a murmur. What should be included in the nurse's documentation? Select all that apply.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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