Heart sounds are loudest for S1 at the __ and S2 at the _.

Right side of the heart.

Center of the heart.

Apex of the heart.

Base of the heart.

Left side of the heart.

Answer and Explanation

Correct Answer : C,D

Choice A rationale
The right side of the heart is not specifically associated with the loudest heart sounds for S1 or S213.
Choice B rationale
The center of the heart is not specifically associated with the loudest heart sounds for S1 or S213.
Choice C rationale
The apex of the heart is where S1 is loudest. S1 is caused by the closure of the mitral and tricuspid valves and is best heard at the apex.
Choice D rationale
The base of the heart is where S2 is loudest. S2 is caused by the closure of the aortic and pulmonic valves and is best heard at the base.
Choice E rationale
The left side of the heart is not specifically associated with the loudest heart sounds for S1 or S213.

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Correct Answer is B

Explanation

A. Document the presence of borborygmi.Loud, high-pitched, and almost continuous gurgling sounds can indicate borborygmi.However, the nurse should not immediately document without fully assessing all four quadrants to ensure a comprehensive evaluation of bowel sounds.

B. Auscultate the remaining quadrants.A complete assessment of bowel sounds involves auscultating all four quadrants to determine if the sounds are generalized, localized, or absent in other areas. This provides a more accurate assessment of the client’s gastrointestinal function.

C. Elevate the head of the client’s bed immediately.The client’s position does not typically affect bowel sounds, and elevating the head of the bed is unnecessary unless the client has difficulty breathing or other non-gastrointestinal concerns.

D. Use the bell of the stethoscope to auscultate again.Using the bell, which is intended for low-pitched sounds like bruits or heart murmurs, would not provide any additional relevant information.

A. Clavicle. B. Lung apex. C. Aortic site. D. Sternum.

Correct Answer is B

Explanation

Choice A rationale
Placing the stethoscope over the clavicle is not the correct starting point for systematically auscultating anterior breath sounds.
Choice B rationale
The nurse should begin by placing the stethoscope over the lung apex, which is located just above the clavicle. This ensures a systematic approach to auscultation.
Choice C rationale
The aortic site is not relevant for auscultating breath sounds; it is used for cardiac auscultation.
Choice D rationale
Placing the stethoscope over the sternum is not the correct starting point for auscultating breath sounds.

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Heart sounds are loudest for S1 at the ______ and S2 at the _____.

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Naxlex Comprehensive Predictor Exams

After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high-pitched almost continuous gurgling in two quadrants. Which action should the nurse implement first?

Correct Answer is B

Explanation

When systematically auscultating a client’s anterior breath sounds, the nurse should begin by placing the stethoscope over which location?

Correct Answer is B

Explanation

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Heart sounds are loudest for S1 at the __ and S2 at the _.