The nurse is informed that a patient had abnormal heart sounds during the night shift. When auscultating abnormal heart sounds, the nurse knows to listen to heart sounds with the:
bell of the stethoscope on top of the patient's gown.
diaphragm of the stethoscope directly on the patient's skin.
diaphragm of the stethoscope on top of the patient's gown.
bell of the stethoscope directly on the patient's skin.
The Correct Answer is B
A. The bell is used to detect low-pitched sounds, but abnormal heart sounds are often high-pitched, requiring the diaphragm.
B. The diaphragm of the stethoscope is best for detecting high-pitched heart sounds, such as murmurs or abnormal rhythms.
C. The diaphragm on top of the gown would create interference and prevent proper auscultation of heart sounds.
D. The bell is used for lower-pitched sounds and is not the best choice for auscultating abnormal heart sounds.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A murmur or swishing sound does not correspond to the diastolic pressure; it is more indicative of turbulent blood flow.
B. Clear tapping sounds are heard at systolic pressure but do not indicate diastolic pressure.
C. Knocking sounds are associated with systolic pressure, not diastolic.
D. The muffling sound heard after the first Korotkoff sounds indicates the diastolic pressure in children and some adults, which is the correct method for assessing the diastolic reading.
Correct Answer is ["A","C"]
Explanation
A. A dialysis shunt requires careful monitoring to avoid damaging the shunt, and blood pressure cuffs should not be applied to the arm with a shunt.
B. A hand amputation does not affect the use of the blood pressure cuff, but care should be taken with the affected area.
C. A previous mastectomy increases the risk of lymphedema, and using a blood pressure cuff on the affected arm could exacerbate this.
D. A patent IV line is not a contraindication for blood pressure measurement, but the nurse should take care not to interfere with the IV.
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