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The nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that using the bell of the stethoscope is appropriate to auscultate for which type of sounds?

Heart murmurs (S3, S4)

Breath sounds

Normal heart (S1,S2)

Bowel sounds

Answer and Explanation

The Correct Answer is A

A. The bell of the stethoscope is used to detect low-pitched sounds such as heart murmurs (S3 and S4).

B. Breath sounds are typically auscultated using the diaphragm of the stethoscope.

C. Normal heart sounds (S1, S2) are best heard using the diaphragm of the stethoscope.

D. Bowel sounds are auscultated using the diaphragm, not the bell.

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Correct Answer is A

Explanation

A. Hydrochlorothiazide is known to increase blood glucose levels, particularly in clients with diabetes or those at risk for glucose intolerance.

B. Dysrhythmias are more commonly associated with electrolyte imbalances like low potassium, but elevated glucose is more specific to hydrochlorothiazide use.

C. Hydrochlorothiazide typically lowers blood pressure, so elevated blood pressure is not a common nontherapeutic response.

D. Impaired airway is unrelated to hydrochlorothiazide use.

A. Pressure ulcers B. Contractures of the extremities C. development of deep vein thrombosis D. Crackles in the lungs E. Polyuria F. Diarrhea

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

Explanation

A. Immobile patients are at high risk for developing pressure ulcers due to prolonged pressure on the skin, leading to tissue breakdown.

B. Contractures of the extremities can occur as a result of muscle atrophy and lack of movement in immobilized patients.

C. Immobility increases the risk of venous stasis, leading to the development of deep vein thrombosis (DVT).

D. Crackles in the lungs may result from immobility due to fluid accumulation or atelectasis, particularly in patients who are not moving or changing position frequently.

E. Polyuria is not commonly associated with immobility.

F. Diarrhea is not commonly associated with immobility.

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The nurse performs an admission assessment on a client admitted with chest pain. The nurse knows that using the bell of the stethoscope is appropriate to auscultate for which type of sounds?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is receiving the diuretic hydrochlorothiazide. When evaluating the client's response to hydrochlorothiazide, which common nontherapeutic response is important for the nurse to monitor?

Correct Answer is A

Explanation

A nurse has been assigned four patients of which one of the patients is completely immobile. Which complication should the nurse expect as a result of immobility? (Select all that apply.)

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

Explanation

In caring for a quadriplegic client which action would the nurse implement to prevent skin breakdown?

The nurse is developing a plan of care for a client who will be admitted to the medical-surgical unit with a diagnosis of deep vein thrombosis (DVT) of the right leg. What should be included in the client's care plan?

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What physical assessment technique would the nurse use to obtain a pulse on a client?

A nurse in the community clinic is providing care to a client who is anxious and hyperventilating. What should the nurse do to reduce the risk of respiratory alkalosis?

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While completing a comprehensive assessment of a client who is admitted with chronic obstructive pulmonary disorder, the objective data revealed the client's nails appear convexed and wide with an angle greater than 160 degrees. How would the nurse document this finding?

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