While auscultating heart sounds, asking the client to turn onto a left lying position would help the nurse assess the presence of which of the following?

Aortic murmurs

Atrial repolarization

The first heart sound

Mitral stenosis

Answer and Explanation

The Correct Answer is D

A. Aortic murmurs: These are best assessed with the client in an upright or slightly leaning forward position, not specifically the left lateral position.

B. Atrial repolarization: This is not directly assessed by body position; it is part of the ECG assessment.

C. The first heart sound: The first heart sound (S1) is heard throughout the auscultation process and is not specifically enhanced by a left lateral position.

D. Mitral stenosis: The left lateral position allows better auscultation of the mitral area, where mitral stenosis murmurs are best heard.

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Correct Answer is B

Explanation

A. Diverticulosis: Murphy's sign is not used to diagnose diverticulosis.

B. Acute Cholecystitis: Murphy's sign is a clinical test used to identify acute cholecystitis. It is positive when the patient experiences pain upon palpation of the gallbladder area during inhalation.

C. Appendicitis: Murphy's sign is not associated with appendicitis; instead, other signs such as McBurney’s point tenderness are used.

D. Nephrolithiasis: Murphy's sign is not indicative of nephrolithiasis; kidney stones are assessed through other signs and symptoms.

A. Perform abdominal percussion, and then repeat auscultation. B. Palpate the client's abdomen to stimulate bowel motility. C. Repeat auscultation in four to six hours. D. Listen for five minutes before documenting an absence of bowel sounds.

Correct Answer is D

Explanation

A. Perform abdominal percussion, and then repeat auscultation: While percussion can provide additional information, the absence of bowel sounds should first be confirmed by listening for a longer period before moving to other techniques.

B. Palpate the client's abdomen to stimulate bowel motility: Palpation is not recommended to stimulate bowel sounds; it may alter the assessment.

C. Repeat auscultation in four to six hours: Immediate reassessment after five minutes of auscultation is preferable to prolonged waiting.

D. Listen for five minutes before documenting an absence of bowel sounds: To ensure accurate assessment, the nurse should listen for up to five minutes in each quadrant

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While auscultating heart sounds, asking the client to turn onto a left lying position would help the nurse assess the presence of which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A positive Murphy's sign is indicative of?

Correct Answer is B

Explanation

The nurse is auscultating a client's abdomen and is unable to discern any bowel sounds. How should the nurse proceed with assessment?

Correct Answer is D

Explanation

When assessing for appendicitis, what signs might the nurse look for? (Select all that apply.)

The nurse knows screening test(s) for colorectal cancer detection according to recommendations from the American Cancer Society (2018) includes? (Select all that apply.)

Aortic insufficiency/regurgitation murmur is classified as a:

A group of nurses is reviewing several electrocardiograms (ECGs). The students demonstrate an understanding of the waveforms when they identify which component as indicating ventricular repolarization (relaxation).

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