The nurse is preparing to auscultate for heart sounds. Which technique is correct?
a. Listening to the sounds at the aortic, tricuspid, pulmonic, and mitral areas
b. Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex
c. Listening to the sounds only at the site where the apical pulse is felt to be the strongest
d. Listening for all possible sounds at a time at each specified area
Question 2The nurse is examining a patient who has possible cardiac enlargement. Which statement about percussion of the heart is true?
a. Percussion is a useful tool for outlining the heart's borders.
b. Percussion is easier in patients who are obese.
c. Studies show that percussed cardiac borders do not correlate well with the true cardiac border.
d. Only expert health care providers should attempt percussion of the heart.
Question 3During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse?
a. Third left intercostal space at the midclavicular line
b. Fourth left intercostal space at the sternal border
c. Fourth left intercostal space at the anterior axillary line
d. Fifth left intercostal space at the midclavicular line
Question 4During the cardiac auscultation, the nurse hears a sound immediately occurring after the S2 at the second left intercostal space. To further assess this sound, what should the nurse do?
a. Have the patient turn to the left side while the nurse listens with the bell of the stethoscope.
b. Ask the patient to hold his or her breath while the nurse listens again.
c. No further assessment is needed because the nurse knows this sound is an S3.
d. Watch the patient's respirations while listening for the effect on the sound.
Question 5When listening to heart sounds, the nurse knows that the S1:
a. Is louder than the S2 at the base of the heart.
b. Indicates the beginning of diastole.
c. Coincides with the carotid artery pulse.
d. Is caused by the closure of the semilunar valves.
Question 6During an inspection of the precordium of an adult patient, the nurse notices the chest moving in a forceful manner along the sternal border. This finding most likely suggests a(n):
a. Normal heart.
b. Systolic murmur.
c. Enlargement of the left ventricle.
d. Enlargement of the right ventricle.
Question 7During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate:
a. Valvular disorder.
b. Blood flow turbulence.
c. Fluid volume overload.
d. Ventricular hypertrophy.
Question 8In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would:
a. Palpate the artery in the upper one third of the neck.
b. Listen with the bell of the stethoscope to assess for bruits.
c. Simultaneously palpate both arteries to compare amplitude.
d. Instruct the patient to take slow deep breaths during auscultation.
Question 9The mother of a 3-month-old infant states that her baby has not been gaining weight. With further questioning, the nurse finds that the infant falls asleep after nursing and wakes up after a short time, hungry again.
What other information would the nurse want to have?
a.
Infant's sleeping position
b.
Sibling history of eating disorders
c.
Amount of background noise when eating
d.
Presence of dyspnea or diaphoresis when sucking
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