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 B

Explanation

A. This is incorrect because it describes an actual nursing diagnosis, not a risk diagnosis.
B. A risk diagnosis describes a situation in which a problem will likely occur if the nurse does not intervene. It identifies a potential health problem that has not yet developed but could occur due to the client’s risk factors.
C. This is incorrect because it describes a health promotion diagnosis, which focuses on enhancing well-being rather than preventing a problem.
D. This is incorrect because it describes a syndrome diagnosis, which is a group of related nursing diagnoses that occur together.

A. Consult clinical resources explaining the client's diagnosis B. Perform a mini overview of the client's body systems. C. Obtain and organize materials you will need for the assessment. D. Review client's medical record

Correct Answer is D

Explanation

A. Consulting clinical resources is helpful but should be done after reviewing the client’s specific information.
B. Performing a mini overview of body systems occurs during the assessment, not before meeting the client.
C. Gathering materials is important but comes after understanding the client’s history.
D. Reviewing the client’s medical record is correct because it helps the nurse gather baseline information, understand past medical history, and prepare for the assessment effectively.

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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 nursing student correctly describes a risk diagnosis by which of the following statements?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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