The nurse is performing a focused cardiovascular assessment on a 70-year-old client. What finding would be considered abnormal? No palpable vibration felt over the precordium (chest wall)

S1 and S2 heard with diaphragm of stethoscope

A blowing sound heard over the mitral area with the bell of the stethoscope

Apical pulse palpated at 5th intercostal space, midclavicular line

Absent sound over carotid arteries with bell of the stethoscope

Answer and Explanation

The Correct Answer is B

A. S1 and S2 heard with the diaphragm of the stethoscope is a normal finding, as these are the expected heart sounds.
B. A blowing sound heard over the mitral area with the bell of the stethoscope suggests a possible murmur, which could indicate valvular abnormalities and is considered abnormal.
C. Apical pulse palpated at the 5th intercostal space, midclavicular line is normal and expected in adults.
D. Absence of sound over carotid arteries with the bell of the stethoscope indicates no bruits and is considered normal.

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Correct Answer is ["A","B"]

Explanation

A. Inquiring about personal and family cardiac history provides essential subjective information on potential hereditary risks and the client’s own cardiac health.
B. Asking about fatigue and chest pain allows the nurse to assess symptoms that may suggest cardiac issues, making it critical subjective data.
C. Inspecting for intercostal retractions and nasal flaring is part of the objective assessment rather than subjective data.
D. Palpating the chest for thrills and heaves is also an objective action, assessing physical findings rather than subjective symptoms.
E. Auscultating the heart with the diaphragm and bell of the stethoscope is an objective assessment to detect sounds rather than gathering subjective information from the client.

A. Respiratory rate of 20 B. Vesicular sounds heard in the lung periphery C. Capillary refill time of 5 seconds D. AP diameter of 1:2 E. Equal chest expansion

Correct Answer is C

Explanation

A. A respiratory rate of 20 is within the normal range for adults (12-20 breaths per minute), especially in someone experiencing dyspnea.
B. Vesicular sounds in the lung periphery are normal findings, particularly in healthy lung areas.
C. A capillary refill time of 5 seconds indicates poor perfusion and could suggest systemic issues or hypoxia, which is concerning in a patient with dyspnea.
D. An anteroposterior (AP) diameter of 1:2 is normal; a barrel chest might indicate chronic respiratory conditions but is not an immediate concern in this context.
E. Equal chest expansion is a normal finding and indicates effective respiratory mechanics.

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The nurse is performing a focused cardiovascular assessment on a 70-year-old client. What finding would be considered abnormal? No palpable vibration felt over the precordium (chest wall)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What subjective data should the nurse obtain about a client's cardiac status? Select all that apply.

Correct Answer is ["A","B"]

Explanation

The nurse is on the medical/surgical floor is getting a new admission. The client is being admitted for shortness of breath (dyspnea). Which assessment finding would be of concern?

Correct Answer is C

Explanation

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