The nurse detects a possible extra heart sound while assessing an adult client. To verify this finding, which action should the nurse take?

Listen to the heart sounds using the bell of a stethoscope.

Use a Doppler ultrasound to hear the heartbeat.

Obtain a pulse oximeter reading from two extremities.

Auscultate for one minute with the stethoscope's diaphragm.

Answer and Explanation

The Correct Answer is A

A.   The bell of the stethoscope is best for detecting low-pitched sounds like murmurs or extra heart sounds.
B.   A Doppler ultrasound is not necessary for routine auscultation of heart sounds.
C.   Pulse oximetry does not provide relevant information about heart sounds.
D.   Auscultating with the diaphragm is better for high-pitched sounds, so the bell is preferred for extra heart sounds.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Observing pupillary response to a penlight helps assess the neurological function related to the eyes, such as reaction to light, but it does not directly assess the client's overall visual acuity or support the claim of being legally blind.
B. Examining the optic disc can help identify structural changes in the eye, such as damage to the retina or optic nerve, but it doesn't directly assess the client’s claim of being legally blind or the extent of visual impairment.
C. Assessing eye movements can help evaluate for conditions such as strabismus or cranial nerve abnormalities, but it doesn't provide a direct assessment of visual acuity or support the client’s statement of blindness.
D. The Snellen chart is a standard tool for assessing visual acuity and is the most appropriate method to objectively measure whether the client has the visual impairment consistent with being legally blind.

A. Ask the client if he took any pain medication at home. B. Observe for nonverbal signs to measure pain intensity. C. Use a standard pain assessment questionnaire and scale. D. Collect a urine sample and strain for granules or calculi.

Correct Answer is D

Explanation

A. While it’s important to assess whether the client has already taken pain medication, this should not be the first intervention. The priority is to assess the client's current status and gather information to guide the next steps in care.
B. Observing nonverbal signs of pain can be helpful, but the first priority is to assess the cause of the pain and collect pertinent data to determine if it’s related to kidney stones or another condition. Nonverbal signs are secondary to clinical assessment.
C. Using a pain scale would be appropriate after performing an initial assessment to determine the cause of the pain. While this helps gauge pain intensity, it is not the most urgent action in the case of suspected kidney stones.
D. The first priority in a client with flank pain and a history of kidney stones is to collect a urine sample and strain it for calculi.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse detects a possible extra heart sound while assessing an adult client. To verify this finding, which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client states, "I am legally blind." Which assessment technique should the nurse use to obtain subjective data to support the client's statement?

Correct Answer is D

Explanation

The nurse is assessing a client who has a history of kidney stones and returns to the clinic with flank pain. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

The school nurse is interviewing a 13-year-old girl who wants to go home from school because of "back pain." Which question should the nurse ask the adolescent first?

An older adult client is being evaluated for admission to an assisted living facility. During the health assessment, the nurse implements which technique to determine the client's ability to reside in this environment?

When assessing an older adult client, which finding is most indicative of dehydration?

When performing a skin and nail exam on an older adult female client, the nurse notes that she has longitudinal ridges on her fingernails. What does this finding indicate?

When assessing a client's range of motion, the nurse notes crepitation with movement of the left knee. Which information in the client's history is most likely related to this finding?

When conducting a physical examination, the nurse uses a tuning fork to assess for which condition?

When assessing heart sounds of a client with rheumatic valvular heart disease, where should the nurse place the stethoscope to auscultate the tricuspid valve?