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A nurse is auscultating heart sounds and hears a murmur. What should be included in the nurse's documentation? Select all that apply.

Client's blood pressure

Client's weight

Client's respiratory rate

Intensity of the murmur

Location of the murmur

Client's temperature

Timing of the murmur

Client's medication history

Answer and Explanation

Correct Answer : A,D,E,G

A.   Client's blood pressure is relevant as it can help correlate the murmur with potential cardiac conditions.
B.   Client's weight is not directly related to documenting a heart murmur.
C.   Client's respiratory rate is also not relevant to the murmur documentation unless respiratory symptoms are present.
D.   Intensity of the murmur is important to document, as it helps assess the severity.
E.   Location of the murmur is important for identifying which valve or area of the heart is involved.
F.   Client's temperature is not directly related to documenting a heart murmur.
G.   Timing of the murmur helps in identifying whether it occurs during systole or diastole, aiding in diagnosis.

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Correct Answer is C

Explanation

A. Fixed lymph nodes suggest possible malignancy or infection and are not typical for a healthy individual.
B. Lymph nodes that are large, firm, and fixed to the tissue also suggest infection or malignancy and would be abnormal in a healthy patient.
C. Nonpalpable lymph nodes are a normal finding.
D. Rubbery, discrete, and mobile lymph nodes are indicative of a pathological process.

A. 2nd intercostal space right of the sternal border B. 5th intercostal space medial to mid-clavicular line C. 2nd intercostal space left of the sternal border. D. 4-5th intercostal space left of the sternal border.

Correct Answer is A

Explanation

A. 2nd intercostal space right of the sternal border is the correct location for auscultating the aortic valve.
B. 5th intercostal space medial to the mid-clavicular line is the location for the mitral valve.
C. 2nd intercostal space left of the sternal border is the location for auscultating the pulmonic valve.
D. 4-5th intercostal space left of the sternal border is where the tricuspid valve is auscultated.

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A nurse is auscultating heart sounds and hears a murmur. What should be included in the nurse's documentation? Select all that apply.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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