A nurse is preparing to auscultate for heart sounds on a client. Which technique should be used by the nurse?

Listening for sounds from the apex to the heart to the base of the heart.

Listening to the sounds at the site where the apical pulse is heard to be the loudest.

Listening from the base of the heart across and down, then over to the apex.

Listening to the sounds at the aortic, tricuspid, pulmonic, arid mitral areas.

Answer and Explanation

The Correct Answer is D

A) Listening for sounds from the apex to the heart to the base of the heart: This technique is not the most effective for auscultation of heart sounds. While it may seem logical to start at the apex and move toward the base, heart sounds are best heard at specific anatomical locations where the valves are closest to the chest wall. Moving from apex to base does not follow the traditional systematic approach used to assess all heart sounds.

B) Listening to the sounds at the site where the apical pulse is heard to be the loudest: The apical pulse is typically located at the mitral area (left 5th intercostal space, midclavicular line), and while this is an important location for assessing heart sounds, it is not the recommended approach for auscultation. The nurse should listen to all the key valve areas to fully assess the heart's function and detect abnormalities such as murmurs or extra heart sounds.

C) Listening from the base of the heart across and down, then over to the apex: This approach is not systematic and may cause the nurse to miss important sounds in the other areas of the heart. The base of the heart is located at the top (around the second intercostal space), while the apex is at the bottom (left 5th intercostal space). A more structured method of auscultation is required to ensure all key areas are evaluated.

D) Listening to the sounds at the aortic, tricuspid, pulmonic, and mitral areas: This is the correct technique for auscultating heart sounds. The nurse should listen over the aortic, pulmonic, tricuspid, and mitral valve areas in sequence to assess heart sounds thoroughly. Each of these areas is associated with a specific valve, and auscultation at these locations helps the nurse identify any abnormal heart sounds, such as murmurs, S3, or S4, as well as the timing of S1 and S2 heart sounds. This systematic approach ensures a comprehensive assessment of heart function.

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Correct Answer is B

Explanation

A) Demonstrate that both arteries will be palpated simultaneously to compare amplitude: This is not recommended. Palpating both carotid arteries simultaneously can cause a decrease in blood flow to the brain, potentially leading to dizziness or syncope. It is important to palpate one carotid artery at a time to avoid reducing blood flow to the brain, especially in clients with cardiovascular disease or those at risk of stroke.

B) Instruct the client to take a deep breath and "hold" while the nurse briefly auscultates: This is the correct approach. Instructing the client to hold their breath helps minimize any interference from respiratory sounds while auscultating the carotid arteries for bruits. This technique ensures that breath sounds do not mask any abnormal vascular sounds, such as bruits, which could indicate a blockage or narrowing of the carotid arteries.

C) Discuss that a light will be directed at the neck to observe for pulsations of the artery: Observing pulsations with light is not an appropriate technique for assessing the carotid arteries. Pulsations may be visible in some cases, but palpation and auscultation are the more reliable methods for evaluating the carotid arteries for abnormalities such as bruits or reduced pulse amplitude.

D) Show the client the diaphragm of the stethoscope that will be placed on the neck: While it is appropriate to explain the process to the client, the action of showing the stethoscope is unnecessary at this stage. The focus should be on instructing the client to hold their breath for proper auscultation to listen for any abnormal vascular sounds.

A. Client's oral temperature is 38.40 C (101.2° F). B. Client reports the rash on their back is itchy. C. Client reports nausea following, administration of pain medication. D. Client has a vesicular rash on their upper back. E. Client reports dull, aching pain in lower right call.

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

Explanation

A) Client's oral temperature is 38.4°C (101.2°F):
This is objective data, as it is a measurable, observable finding obtained through direct assessment (in this case, using a thermometer). Objective data are facts or measurements that can be verified or observed by the healthcare provider.

B) Client reports the rash on their back is itchy:
This is subjective data, as it is based on the client's personal experience and report. The feeling of itchiness cannot be directly measured or observed by the nurse; it is something the client experiences and describes. Subjective data include symptoms, sensations, or feelings reported by the client.

C) Client reports nausea following administration of pain medication:
This is subjective data. Nausea is a symptom that the client reports experiencing, which cannot be objectively measured or directly observed by the nurse. It is based on the client's perception and report, making it subjective.

D) Client has a vesicular rash on their upper back:
This is objective data. The rash is something the nurse can observe and describe. Objective data include observable facts, such as physical exam findings, lab results, or diagnostic test results.

E) Client reports dull, aching pain in lower right calf:
This is subjective data, as pain is a sensation that the client experiences and describes. The intensity, location, and type of pain (dull, aching) are subjective experiences that only the client can report.

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A nurse is preparing to auscultate for heart sounds on a client. Which technique should be used by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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

Explanation

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