Exhibits

Heart sounds are loudest for Sl at the
dropdown
and for S2 at the
dropdown

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

S1 (First Heart Sound): S1, often referred to as the "lub" sound, is loudest at the apex of the heart. This is because the apex, located at the bottom of the heart, is where the mitral and tricuspid valves close. The apex is generally found in the left fifth intercostal space, medial to the midclavicular line.
S2 (Second Heart Sound): S2, known as the "dub" sound, is loudest at the base of the heart. The base, located at the top of the heart, is where the aortic and pulmonic valves close. This location is where the sound of the closing of these valves is best heard, typically around the second intercostal space along the left and right sternal borders.

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

Explanation

A. Use a warmed bell of the stethoscope and place it lightly over the four quadrants
Using a warmed stethoscope helps to avoid discomfort for the patient and ensures better transmission of sound. The bell of the stethoscope is effective for detecting low-pitched sounds such as bowel sounds. Lightly placing the stethoscope over the four quadrants of the abdomen allows for thorough assessment of bowel sounds in each area.
B. Place the stethoscope in the ears with the earpieces pointing towards the ears
While this is a standard practice for proper use of a stethoscope to ensure correct sound conduction, it is not specific to assessing bowel sounds. This action is important for accurate auscultation but does not directly relate to the technique of assessing bowel sounds.
C. Turn the suction off while auscultating
Turning off the nasogastric tube suction is crucial because suction noise can interfere with the assessment of bowel sounds. Clear and accurate auscultation of bowel sounds requires a quiet environment to avoid misinterpretation of sounds. Therefore, it is important to turn off any equipment that might create noise during the assessment.
D. Auscultate at least 5 minutes of continuous listening before determining that bowel sounds are absent
Auscultating for a minimum of 5 minutes is essential to confirm the absence of bowel sounds. This extended duration helps in making an accurate assessment, as bowel sounds can be intermittent, and it ensures that transient sounds are not missed. This step is critical before concluding that bowel sounds are absent.
E. Palpate the abdomen before auscultating
Palpating the abdomen before auscultating can alter bowel sounds due to the manipulation of the intestines, potentially leading to inaccurate assessment. It is recommended to auscultate first to avoid affecting the natural bowel sounds before physical examination. Palpation should be done after auscultation to assess for any physical abnormalities or tenderness.

A. Blood urea nitrogen (BUN) B. Glucose C. Hematocrit D. White blood cell count (WBC)

Correct Answer is C

Explanation

A. Blood urea nitrogen (BUN) levels may be elevated in cases of gastrointestinal bleeding due to the breakdown of blood in the intestines, but it is not the primary test to monitor for blood loss.
B. Glucose levels are important to monitor for clients with diabetes or metabolic disorders, but they are not directly related to melena, which is a sign of gastrointestinal bleeding.
C. Hematocrit is a critical lab test to monitor in response to melena, as it measures the proportion of red blood cells in the blood. A decrease in hematocrit indicates blood loss, which is a common consequence of gastrointestinal bleeding.
D. White blood cell count (WBC) is used to monitor infection or inflammation, but it is not directly related to the immediate concern of blood loss associated with melena.

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Exhibits Heart sounds are loudest for Sl at the dropdown and for S2 at the dropdown

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The nurse is assessing the client for bowel sounds. Which intervention(s) would be indicated to assess bowel sounds? Select all that apply.

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

Explanation

The nurse observes that a client is experiencing melena. Which serum laboratory test should the nurse monitor in response to this finding?

Correct Answer is C

Explanation

To assess a client's pupillary reaction to accommodation, which action should the nurse take?

The nurse is obtaining a health history for a client prior to a scheduled cholecystectomy. While interviewing the client, which assessment technique should the nurse use when asking about the client's use of illegal drugs and alcohol?

An adult client presents with gnawing epigastric pain. The pain is worse when the client is hungry and abates after eating something. Which problem do these symptoms suggest?

A male client arrives at the clinic for a follow-up health assessment after recent antibiotic treatment for pneumonia without hospitalization. Which technique should the nurse implement to assess for adventitious lung sounds?

The nurse completes palpation of the thoracic region on an adult client. Which finding is considered normal for this client?

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Exhibits

Heart sounds are loudest for Sl at the
dropdown
and for S2 at the
dropdown