The nurse is having difficulty hearing his patient's apical pulse with his stethoscope. Which action will help the nurse hear the heartbeat more clearly?
Positioning the bell very lightly over the patient's sternum
Placing the diaphragm firmly against the patient's skin
Utilizing a stethoscope with the longest possible tubing
Making sure that the earpieces fit loosely in the nurse's ear canals
The Correct Answer is B
A. Positioning the bell very lightly over the patient's sternum. The bell is best for low-pitched sounds like murmurs, but heartbeats (especially S1 and S2) are better heard with the diaphragm over the apex of the heart, not the sternum.
B. Placing the diaphragm firmly against the patient's skin. The diaphragm is designed to pick up high-pitched sounds like the normal S1 and S2 heart sounds. Pressing firmly helps eliminate external noise and improves sound clarity.
C. Utilizing a stethoscope with the longest possible tubing. Longer tubing can reduce sound transmission quality. Shorter tubing (about 14-18 inches) provides clearer sound.
D. Making sure that the earpieces fit loosely in the nurse's ear canals. Earpieces should fit snugly, not loosely, to ensure optimal sound conduction and block external noise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Axillary. The axillary method is less accurate because it measures surface temperature, which can be influenced by environmental factors and is typically lower than core temperature.
B. Rectal. The rectal route provides the most accurate core temperature measurement because it closely reflects internal body temperature and is less affected by external conditions. It is commonly used in critically ill patients and infants when precise measurements are needed.
C. Forehead. Forehead (temporal artery) thermometers provide a non-invasive method of measuring temperature but can be less accurate due to external factors like sweating or ambient temperature changes.
D. Oral. Oral temperature is commonly used and provides a good estimate of core temperature, but factors like recent eating, drinking, or mouth breathing can affect accuracy. Rectal temperature remains the most precise method.
Correct Answer is C
Explanation
A. Auscultation. Auscultation involves listening to internal body sounds, usually with a stethoscope, such as heart, lung, or bowel sounds. It is not used for assessing the radial pulse.
B. Percussion. Percussion is the technique of tapping on body surfaces to assess underlying structures, such as detecting fluid in the lungs or assessing organ size. It is not used to assess pulses.
C. Palpation. Palpation involves using the fingers to feel for the radial pulse by applying gentle pressure over the radial artery at the wrist. This is the correct method for assessing a patient's radial pulse.
D. Inspection. Inspection involves visually examining the patient for abnormalities such as skin color, swelling, or deformities. It does not provide information about pulse rate or rhythm.
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