The nurse prepares to begin a systematic assessment of a client's heart sounds. Upon positioning the stethoscope as seen in the picture, which should the nurse do first?

Listen for abnormal sounds.

Identify S1 and S2 heart sounds.

Move the stethoscope to the apical site.

Change to the bell of the stethoscope.

Answer and Explanation

The Correct Answer is B

A. Listen for abnormal sounds. Before identifying abnormal sounds, it's essential to first establish a baseline by identifying the normal heart sounds (S1 and S2).

B. Identify S1 and S2 heart sounds. This is the correct first step in a systematic assessment of heart sounds. S1 ("lub") corresponds to the closure of the atrioventricular valves (mitral and tricuspid), while S2 ("dub") corresponds to the closure of the semilunar valves (aortic and pulmonic).

C. Move the stethoscope to the apical site. While the apical site is important for auscultating specific heart sounds, it's best to first identify S1 and S2 at the traditional auscultatory areas (aortic, pulmonic, tricuspid, and mitral).

D. Change to the bell of the stethoscope. The bell of the stethoscope is used to listen for lower-pitched sounds, but it's not typically used for identifying S1 and S2 heart sounds, which are higher-pitched.

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Correct Answer is B

Explanation

A. Observe for eye opening to a painful stimulus: Using a painful stimulus is part of the Glasgow Coma Scale (GCS) assessment for level of consciousness, providing a systematic way to determine the client's response level. This step should follow if the client does not respond to verbal commands.

B. Ask the client to open his eyes: This is a less invasive step that should be attempted first before applying a painful stimulus. It can provide immediate information about the client's level of consciousness and ability to follow commands.

C. Notify the healthcare provider: Notifying the healthcare provider is essential if the client's condition is critical or worsening. However, it should follow after initial assessment steps have been taken to determine the immediate status.

D. Check the pupillary response to light: Checking pupillary response is important for neurological assessment but does not directly address the need to evaluate the client's response to stimuli, which is critical for assessing consciousness levels.

A. Mother's use of alcohol, drugs, or cigarettes during pregnancy. B. List of achievement timeline for developmental milestones. C. A history of rubella, rubeola, or chicken pox. D. Reactions to any previous hospitalizations.

Correct Answer is D

Explanation

A. Mother's use of alcohol, drugs, or cigarettes during pregnancy: While this information might be relevant to the child's medical history, it's not directly related to planning care for the umbilical hernia repair surgery itself.

B. List of achievement timeline for developmental milestones: This information might be helpful for a general paediatric assessment, but it's not crucial for planning care specific to an umbilical hernia repair.

C. A history of rubella, rubeola, or chicken pox: Unless there are complications related to these illnesses, they are not directly relevant to the surgery.

D. Reactions to any previous hospitalizations: This information is vital. Knowing how the child reacted to previous hospitalizations (anaesthesia, medications, separation anxiety) can help the nurse anticipate potential challenges and develop strategies to create a positive experience for the child.

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The nurse prepares to begin a systematic assessment of a client's heart sounds. Upon positioning the stethoscope as seen in the picture, which should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In assessing a male client's level of consciousness, the nurse determines that the client does not open his eyes spontaneously. Which should the nurse do next?

Correct Answer is B

Explanation

A six-year-old girl is being admitted to the hospital for repair of an umbilical hernia. Which information, collected by the admitting nurse, is particularly helpful in planning care for this child?

Correct Answer is D

Explanation

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