A nurse is preparing to auscultate for heart sounds on a client. Which technique should be used by the nurse?

Listening for sounds from the apex to the heart to the base of the heart.

Listening to the sounds at the site where the apical pulse is heard to be the loudest.

Listening from the base of the heart across and down, then over to the apex.

Listening to the sounds at the aortic, tricuspid, pulmonic, arid mitral areas.

Answer and Explanation

The Correct Answer is D

A) Listening for sounds from the apex to the heart to the base of the heart: This technique is not the most effective for auscultation of heart sounds. While it may seem logical to start at the apex and move toward the base, heart sounds are best heard at specific anatomical locations where the valves are closest to the chest wall. Moving from apex to base does not follow the traditional systematic approach used to assess all heart sounds.

B) Listening to the sounds at the site where the apical pulse is heard to be the loudest: The apical pulse is typically located at the mitral area (left 5th intercostal space, midclavicular line), and while this is an important location for assessing heart sounds, it is not the recommended approach for auscultation. The nurse should listen to all the key valve areas to fully assess the heart's function and detect abnormalities such as murmurs or extra heart sounds.

C) Listening from the base of the heart across and down, then over to the apex: This approach is not systematic and may cause the nurse to miss important sounds in the other areas of the heart. The base of the heart is located at the top (around the second intercostal space), while the apex is at the bottom (left 5th intercostal space). A more structured method of auscultation is required to ensure all key areas are evaluated.

D) Listening to the sounds at the aortic, tricuspid, pulmonic, and mitral areas: This is the correct technique for auscultating heart sounds. The nurse should listen over the aortic, pulmonic, tricuspid, and mitral valve areas in sequence to assess heart sounds thoroughly. Each of these areas is associated with a specific valve, and auscultation at these locations helps the nurse identify any abnormal heart sounds, such as murmurs, S3, or S4, as well as the timing of S1 and S2 heart sounds. This systematic approach ensures a comprehensive assessment of heart function.

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Correct Answer is A

Explanation

A) Palpate the chest symmetrically:
Palpating the chest symmetrically is crucial when assessing tactile fremitus, as it allows the nurse to compare the intensity of vibrations felt on both sides of the chest. Tactile fremitus refers to the palpable vibrations transmitted through the bronchopulmonary system when a person speaks or breathes. Symmetrical palpation ensures that the nurse can detect any differences in fremitus, which may indicate abnormalities such as lung consolidation (e.g., pneumonia), pleural effusion, or pneumothorax. Uneven fremitus can suggest a pathological condition, and symmetrical palpation helps identify these variations.

B) Ask the client to cough:
Asking the client to cough is not directly related to the assessment of tactile fremitus. Coughing may be used in other aspects of the respiratory assessment (e.g., to clear secretions or to assess for a productive cough), but it is not necessary for palpating fremitus. Tactile fremitus is assessed while the client is speaking (e.g., repeating the phrase "ninety-nine") or breathing, not coughing.

C) Use the bell of the stethoscope:
The bell of the stethoscope is used for auscultating low-pitched sounds, such as heart murmurs or some lung sounds (e.g., certain adventitious sounds like crackles or wheezes). However, it is not used for palpating tactile fremitus, which is a physical exam technique that involves using the hands to feel for vibrations. Fremitus is a tactile (not auscultatory) finding, so the stethoscope, whether bell or diaphragm, is not relevant in this assessment.

D) Instruct the client to breathe deeply:
While it is important for the client to breathe deeply during a lung exam, deep breathing is not directly required for assessing tactile fremitus. Tactile fremitus is typically assessed while the client is speaking. When the client repeats a phrase like "ninety-nine," vibrations are transmitted through the chest wall, and the nurse can assess the intensity of the vibrations. Deep breathing would be more relevant for assessing breath sounds or the general respiratory effort.

A. S2 indicates the beginning of diastole B. S2 coincides with the carotid artery pulse C. S2 is caused by the closure of the semilunar valves D. S2 is louder than an S1

Correct Answer is C

Explanation

A) S2 indicates the beginning of diastole:
While S2 does coincide with the end of systole and the beginning of diastole, this statement is not the most specific or accurate way to describe the S2 heart sound. S2 marks the closure of the semilunar valves (the aortic and pulmonic valves), which occurs at the end of systole, just before diastole begins. While it is true that the S2 sound occurs as the heart transitions from systole to diastole, the closure of the semilunar valves is the more specific cause of S2.

B) S2 coincides with the carotid artery pulse:
This statement is not accurate. S2 does not exactly coincide with the carotid pulse. The S2 sound is heard slightly after the pulse due to the time it takes for the mechanical contraction of the heart to produce the sound. The carotid pulse typically corresponds more closely with the closure of the atrioventricular (AV) valves and the beginning of systole (S1), not S2. The timing of S2 and the carotid pulse can be close, but they are not perfectly synchronized.

C) S2 is caused by the closure of the semilunar valves:
This is the correct explanation. S2 is the heart sound produced by the closure of the semilunar valves (the aortic and pulmonic valves). The closing of these valves marks the end of systole and the beginning of diastole. S2 is typically described as having two components: the A2 sound (closure of the aortic valve) and the P2 sound (closure of the pulmonic valve). In some cases, particularly during inspiration, A2 and P2 may be heard separately, producing a split S2 sound.

D) S2 is louder than an S1:
This statement is not accurate. In general, S1 is louder than S2 at the apex of the heart (the lower part of the chest). S2 is louder than S1 at the base of the heart (near the sternum), particularly over the aortic and pulmonic areas. The loudness of heart sounds varies based on the location of auscultation, but it is not universally true that S2 is always louder than S1. The intensity of each sound depends on various factors, including the position of the listener and the health of the heart valves.

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A nurse is preparing to auscultate for heart sounds on a client. Which technique should be used by the nurse?

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Naxlex Comprehensive Predictor Exams

A nurse is examining a client for tactile fremitus. The nurse should understand that what action is of primary importance when examining for tactile fremitus?

Correct Answer is A

Explanation

A nurse is listening to the heart sounds of a client. What information about S2 sounds should the nurse recognize as accurate?

Correct Answer is C

Explanation

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