A Medical-Surgical nurse is assessing a client's heart sounds. In which of the following points of auscultation would the nurse hear the S2 sound most clearly?

Pulmonic and Mitral.

Tricuspid and Aortic.

Mitral and Tricuspid.

Aortic and Pulmonic.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Auscultation at the pulmonic and mitral points would not provide the clearest hearing of the S2 heart sound. The S2 sound is composed of two components: A2 (aortic valve closure) and P2 (pulmonic valve closure). The aortic valve sound (A2) is usually louder than P2. Mitral point is not ideal for hearing S2 clearly, as it's mostly associated with S1 sound.

Choice B rationale:

The tricuspid and aortic points are the most appropriate for hearing the S2 heart sound. The aortic valve (A2) is best heard at the second right intercostal space close to the sternum, and the tricuspid valve is best heard at the lower left sternal border.

Choice C rationale:

While the mitral and tricuspid points are important for auscultating the heart sounds, they are more associated with the S1 sound (the first heart sound). The S2 sound is best heard at the aortic and pulmonic areas.

Choice D rationale:

The aortic and pulmonic points are important for assessing the S2 heart sound, but they are not the most optimal locations. The aortic valve sound is heard most clearly at the second right intercostal space, whereas the pulmonic valve sound is heard at the second left intercostal space.

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Correct Answer is C

Explanation

Choice A rationale:

Justice. Justice refers to fair and equitable treatment for all individuals. While it is an important ethical principle, it does not directly relate to the nurse's action of returning a telephone call promptly and as promised. Justice involves issues of fairness and distribution of resources, and it's not the most applicable principle in this context.

Choice B rationale:

Nonmaleficence. Nonmaleficence refers to the principle of "do no harm." While it is crucial in healthcare, it doesn't directly address the nurse's action of returning a client's call promptly. This principle is more concerned with preventing harm in clinical interventions and decision-making.

Choice C rationale:

Fidelity. Fidelity, or faithfulness, is the ethical principle that aligns with the nurse's action in this scenario. By returning the call by the end of the day as promised, the nurse is demonstrating fidelity to the client's trust and expectations. This principle emphasizes the importance of keeping promises and being loyal to commitments made to clients.

Choice D rationale:

Autonomy. Autonomy pertains to an individual's right to make their own decisions about their care and treatment. While autonomy is a vital principle in healthcare, it does not directly relate to the nurse's action of returning a telephone call promptly. Autonomy focuses more on involving the client in their care decisions and respecting their choices.

A. Drowsiness. B. Grimacing. C. Screaming. D. Moaning. E. Restlessness.

Correct Answer is ["B","D","E"]

Explanation

Choice A rationale:

Drowsiness alone may not be a reliable indicator of pain, as it can result from various factors such as medications or the postoperative recovery process. While pain might cause drowsiness in some cases, it is not a definitive nonverbal sign of pain.

Choice B rationale:

Grimacing is a nonverbal behavior that often indicates pain or discomfort. It involves facial expressions of pain, such as frowning or wincing. Grimacing is a significant indicator that the nurse should consider in assessing the client's pain level.

Choice C rationale:

Screaming is a more overt expression of pain and discomfort. However, it is less common in a postoperative setting and might also be associated with anxiety or other emotional states. While it can indicate pain, it's not as reliable a marker as grimacing, moaning, or restlessness.

Choice D rationale:

Moaning is a nonverbal behavior that can signal pain in a postoperative client. It's an audible expression of discomfort and should be considered as a potential indication of pain.

Choice E rationale:

Restlessness can be an indication of pain as well. The client may shift positions frequently or exhibit signs of agitation in response to pain. However, restlessness can also have other causes, such as anxiety or medication effects.

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A Medical-Surgical nurse is assessing a client's heart sounds. In which of the following points of auscultation would the nurse hear the S2 sound most clearly?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a provider's office returns a telephone call by the end of the day, as promised, to a client who is worried about the outcome of a laboratory test. The nurse is demonstrating which of the following ethical principles?

Correct Answer is C

Explanation

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Correct Answer is ["B","D","E"]

Explanation

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