A nurse experiences difficulty auscultating the heart sounds of a client. What should the nurse do to assure they are able to auscultate the heart sounds?

Place the diaphragm against the client's clothing and angle biannuals toward nose.

Ensure that the ear pieces are loose and comfortable in ears.

Ask the client to hold their breath during auscultation.

Eliminate distracting noises from the environment and ensure a snug fit with the ear pieces.

Answer and Explanation

The Correct Answer is D

A. Placing the diaphragm against clothing can interfere with sound transmission. The stethoscope should be placed directly on the skin.
B. Earpieces should fit snugly in the ears to optimize sound conduction, rather than being loose.
C. Asking the client to hold their breath is not a standard technique for improving heart sound auscultation; it is more useful for breath sounds or murmurs.
D. "Eliminate distracting noises from the environment and ensure a snug fit with the ear pieces" is correct because background noise can interfere with auscultation, and a proper fit enhances sound transmission.

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Correct Answer is C

Explanation

A. Pressing in the right upper quadrant is not appropriate for a referred rebound tenderness test, which is used to assess peritoneal irritation, commonly from appendicitis.
B. Pressing in the left upper quadrant is not useful in diagnosing appendicitis or conditions that cause referred pain to the right lower quadrant.
C. Pressing in the left lower quadrant is correct when performing Rovsing’s sign, a test for referred rebound tenderness. If the client experiences pain in the right lower quadrant when the left lower quadrant is pressed, it suggests peritoneal irritation, often due to appendicitis.
D. Pressing in the right lower quadrant would directly elicit tenderness in appendicitis but does not test for referred rebound tenderness.

A. Carbohydrate deficiency B. Vitamin B12 deficiency C. Protein deficiency D. Vitamin A deficiency

Correct Answer is C

Explanation

A. Carbohydrate deficiency can lead to low energy levels and weight loss, but it is not primarily associated with edema, brittle nails, or dry hair.
B. Vitamin B12 deficiency can cause neurological symptoms and anemia, but it does not typically lead to edema or brittle nails.
C. Protein deficiency is correct because it can cause muscle wasting, poor wound healing, thin and dry hair, brittle nails, and edema due to low albumin levels.
D. Vitamin A deficiency is primarily linked to vision problems, dry skin, and an increased risk of infections but does not typically cause edema or brittle nails.

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A nurse experiences difficulty auscultating the heart sounds of a client. What should the nurse do to assure they are able to auscultate the heart sounds?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is brought to the acute hospital setting with severe abdominal pain. The nurse is evaluating a new graduate's ability to perform a referred rebound tenderness test. The nurse identifies correct technique when the new graduate is observed pressing deeply at which abdominal location?

Correct Answer is C

Explanation

A client has come into the clinic with complaints of anorexia for one month with a noted 20-pound weight loss in the past six weeks. The nurse notes mild edema to the lower extremities, thin, dry hair, and brittle nails. What deficiency are these findings most likely related to?

Correct Answer is C

Explanation

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