To determine the quality and intensity of a cardiac murmur, the nurse would take which action?

Use the bell of the stethoscope

Palpate the chest wall to feel the intensity of the murmur

Use a Doppler ultrasound device

Percuss the thorax cavity

Answer and Explanation

The Correct Answer is A

A. The bell of the stethoscope is best used to listen for low-pitched sounds, including some types of murmurs, and can help assess the quality and intensity of a cardiac murmur.

B. While palpation can provide some information about the heart's function (such as thrills), it is not the primary method for assessing the quality of a murmur.

C. A Doppler ultrasound device is used for measuring blood flow and can help in assessing murmurs but does not provide the quality assessment needed for characterizing a murmur.

D. Percussion is not typically used to evaluate murmurs; it is more useful for assessing the size and borders of organs.

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Correct Answer is C

Explanation

A. Metabolic alkalosis is characterized by a high pH and elevated bicarbonate levels, which is not present in these results.

B. Respiratory alkalosis would present with an increased pH and decreased PaCO2, which does not apply here.

C. The low pH (7.12) indicates acidemia, and the elevated PaCO2 (90 mm Hg) suggests hypoventilation and respiratory acidosis due to CO2 retention. The bicarbonate level is within normal limits, further supporting respiratory acidosis.

D. Metabolic acidosis would be indicated by a low pH and low bicarbonate levels; however, the bicarbonate is normal in this case, ruling out metabolic acidosis.

A. Severity of the condition B. Vital signs C. Nonverbal behavior D. Self-rating of pain

Correct Answer is D

Explanation

A. The severity of the condition may correlate with pain but is not a direct measure of the individual's pain experience.

B. Vital signs can change due to pain but are not specific indicators of pain intensity or presence.

C. Nonverbal behavior can provide clues about pain but is subjective and can vary greatly between individuals.

D. Self-rating of pain is considered the most reliable indicator of pain because it reflects the individual's personal experience and perception of their pain, making it the gold standard for assessing pain intensity.

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To determine the quality and intensity of a cardiac murmur, the nurse would take which action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is found unresponsive has arterial blood gases drawn, and the results indicate the following: - pH is 7.12 (normal range: 7.35-7.45) - PaCO2 is 90 mm Hg (normal range: 35-45) - HCO3- is 22 mEq/L (normal range: 22-26) The nurse interprets the results as indicating which condition?

Correct Answer is C

Explanation

A nurse is performing a pain assessment for an alert client. Which measure should the nurse recognize as the most reliable indicator of pain?

Correct Answer is D

Explanation

To determine the quality and intensity of a cardiac murmur, the nurse would take which action?

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