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?
I
X
II
III
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Diverticulosis: Murphy's sign is not used to diagnose diverticulosis.
B. Acute Cholecystitis: Murphy's sign is a clinical test used to identify acute cholecystitis. It is positive when the patient experiences pain upon palpation of the gallbladder area during inhalation.
C. Appendicitis: Murphy's sign is not associated with appendicitis; instead, other signs such as McBurney’s point tenderness are used.
D. Nephrolithiasis: Murphy's sign is not indicative of nephrolithiasis; kidney stones are assessed through other signs and symptoms.
Correct Answer is C
Explanation
A. Pulmonic and tricuspid: The tricuspid valve's closure is not primarily audible at the 2nd intercostal space right sternal border; it is better heard at the lower left sternal border.
B. Mitral and aortic: The mitral valve is best heard at the apex of the heart, not the 2nd intercostal space right sternal border.
C. Aortic and pulmonic: The 2nd intercostal space right sternal border is the area where the aortic and pulmonic valves are auscultated. The louder S2 here indicates the closure of these valves, with the aortic valve being the primary source of sound in this area.
D. Tricuspid and mitral: These valves are best heard at other locations, with the tricuspid valve near the lower left sternal border and the mitral valve at the apex.
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