While auscultating heart sounds, the nurse hears a murmur. Which of these modes should be used to assess this murmur?
Bell of the stethoscope
Palpation with the nurse's palm of the hand
Electrocardiography
Diaphragm of the stethoscope
The Correct Answer is A
A. Bell of the stethoscope:
The bell is best for hearing low-pitched sounds like certain murmurs.
B. Palpation with the nurse's palm of the hand:
Palpation can detect thrills or vibrations but cannot auscultate murmurs.
C. Electrocardiography:
ECG records electrical activity but does not assess heart sounds.
D. Diaphragm of the stethoscope:
Best for high-pitched sounds like breath or bowel sounds, not low-pitched murmurs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Bronchial sounds:
Normal over the trachea; not an adventitious sound.
B. Wheezes:
High-pitched musical sounds caused by air flowing through narrowed airways, typical in asthma.
C. Bronchophony:
A vocal resonance test, not a breath sound.
D. Whispered pectoriloquy:
Another voice transmission test-indicates consolidation but is not a breath sound.
Correct Answer is D
Explanation
A. Return to do a re-assessment in 30 minutes:
Delays addressing the finding. The nurse must determine if the crackles are transient or persistent.
B. Inform the co-assigned nurse:
Not a priority action. The nurse should reassess directly before involving others.
C. Ask the patient if he needs his puffer:
Puffers are used for bronchoconstriction; crackles are usually not treated this way unless wheezing is present.
D. Instruct the patient to take a few breaths and cough:
This helps determine if the crackles are transient (e.g., atelectasis) or indicative of a more serious issue (e.g., fluid overload). If they clear, it’s likely atelectasis.
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