During chest auscultation, the nurse hears a quiet murmur immediately upon placing the stethoscope on the client's chest. The nurse interprets this as which grade?

III

Answer and Explanation

The Correct Answer is A

A. I: A grade I murmur is very faint and may not be heard immediately without careful listening. The description of a murmur heard immediately upon placing the stethoscope indicates it is a grade I.

B. X: There is no grade X in the standard grading scale for heart murmurs.

C. II: A grade II murmur is quiet but easily heard with a stethoscope and would generally be more audible than described.

D. III: A grade III murmur is moderately loud and would be heard without difficulty. The description suggests a quieter murmur.

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Correct Answer is C

Explanation

A. Antidepressant: Antidepressants are not typically associated with a high risk of thrombophlebitis.

B. Antihypertensive: Antihypertensives generally do not increase the risk of thrombophlebitis.

C. Oral contraceptive: Oral contraceptives are known to increase the risk of thrombophlebitis due to their effect on blood clotting factors.

D. Antilipid agent: Antilipid agents, such as statins, do not commonly cause thrombophlebitis.

A. Perform abdominal percussion, and then repeat auscultation. B. Palpate the client's abdomen to stimulate bowel motility. C. Repeat auscultation in four to six hours. D. Listen for five minutes before documenting an absence of bowel sounds.

Correct Answer is D

Explanation

A. Perform abdominal percussion, and then repeat auscultation: While percussion can provide additional information, the absence of bowel sounds should first be confirmed by listening for a longer period before moving to other techniques.

B. Palpate the client's abdomen to stimulate bowel motility: Palpation is not recommended to stimulate bowel sounds; it may alter the assessment.

C. Repeat auscultation in four to six hours: Immediate reassessment after five minutes of auscultation is preferable to prolonged waiting.

D. Listen for five minutes before documenting an absence of bowel sounds: To ensure accurate assessment, the nurse should listen for up to five minutes in each quadrant

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During chest auscultation, the nurse hears a quiet murmur immediately upon placing the stethoscope on the client's chest. The nurse interprets this as which grade?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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