A nursing student is preforming a head-to-toe assessment on his patient with a history of mitral regurgitation. Instead of hearing normal heart sounds the student hears a murmur.

Which of the following best describes the sound of a heart murmur?

Lub-dub sounds

Gentle blowing or swooshing noise

Scratchy, leathery heart noise

Abrupt, high-pitched snapping noise

Answer and Explanation

The Correct Answer is B

A. Lub-dub sounds:

This describes the normal heart sounds, with the "lub" representing the closing of the mitral and tricuspid valves (S1) and the "dub" representing the closing of the aortic and pulmonic valves (S2). This is the typical and expected sound of a healthy heart.

B. Gentle blowing or swooshing noise:

This describes the characteristic sound of a heart murmur. Murmurs are abnormal sounds caused by turbulent blood flow, and they are often described as a gentle blowing or swooshing noise heard between the normal heart sounds.

C. Scratchy, leathery heart noise:

This description is not typical for heart sounds or murmurs. Heart sounds are usually described in terms of tones, clicks, or swooshing rather than scratchy or leathery.

D. Abrupt, high-pitched snapping noise:

This description is not typical for heart sounds or murmurs. Heart murmurs are generally characterized by a more continuous, blowing, or swooshing quality, rather than abrupt, high-pitched snapping noises.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Dorsal surface of the foot:

The skin on the dorsal surface of the foot may have more pigmentation, making it potentially more challenging to detect cyanosis in individuals with dark skin.

B. Pinnae of the ears:

The ears may have variable pigmentation, and the presence of hair can affect the visibility of cyanosis. The skin on the pinnae may not be as thin as the skin on the dorsal surface of the hand.

C. Dorsal surface of the hand

When assessing for cyanosis in a client with dark skin, the nurse should examine areas with less pigmentation or areas where the skin is thin. The dorsal surface of the hand is often a suitable site, as it is less pigmented and can show bluish discoloration if cyanosis is present.

D. Conjunctivae:

The conjunctivae (the mucous membranes lining the inner surface of the eyelids and covering the white part of the eyes) are not a reliable site for assessing cyanosis in individuals with dark skin. Mucous membranes may not show cyanosis as prominently as the skin.

A. “I will begin upon the client’s admission to the facility.” B. “I will begin once the client’s insurance company approves discharge coverage.” C. “I will begin 48 hr before the client’s discharge.” D. “I will begin once the client’s discharge order is written.”

Correct Answer is A

Explanation

A. “I will begin upon the client’s admission to the facility.”

Effective discharge planning should start upon the client's admission to the facility. It is an ongoing process that involves assessing the patient's needs, planning for post-discharge care, and ensuring a smooth transition from the hospital to the next level of care. Early initiation of discharge planning allows the healthcare team to address any potential barriers, educate the patient and their family, and coordinate necessary resources for a successful transition.

B. “I will begin once the client’s insurance company approves discharge coverage.”

Waiting for insurance approval may delay the discharge planning process and hinder the timely coordination of resources needed for post-discharge care.

C. “I will begin 48 hr before the client’s discharge.”

Waiting until 48 hours before discharge may not allow sufficient time to address all aspects of the discharge plan, potentially leading to rushed or incomplete preparations.

D. “I will begin once the client’s discharge order is written.”

Waiting for the discharge order may delay the start of the planning process, and effective discharge planning should be initiated earlier to ensure comprehensive and patient-centered care.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nursing student is preforming a head-to-toe assessment on his patient with a history of mitral regurgitation. Instead of hearing normal heart sounds the student hears a murmur. Which of the following best describes the sound of a heart murmur?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

Correct Answer is C

Explanation

Correct Answer is A

Explanation

A nurse is preparing to collect health history data during a client’s admission. Which of the following questions should the nurse use to promote this discussion?

Ordered: furosemide (Lasix) 20mg Available: furosemide (Lasix) 2 mg/2 mL Administer: ____mL

A nurse is completing a client’s history and physical examination. Which of the following information should the nurse consider subjective data?

Ordered: Digoxin (Lanoxin) 0.25 mg Available: Digoxin (Lanoxin) 0.125 mg per tablet Administer: _____tab(s)

A nurse is preparing to measure a client’s level of oxygen saturation on a patient who has had a bilateral lower leg amputation. He noticed the patient’s hands are very edematous. The nurse should apply the pulse oximeter probe to which of the following locations?

A nurse is assessing a client’s circulatory system. Which of the following pulse sites should the nurse avoid assessing bilaterally at the same time?

A nurse in the ER is caring for a patient who had fallen at home. She reviews the blood pressure reading of 160/80 mm Hg. The client denies any history of hypertension. Which of the following actions should the nurse take first?

A nursing student is preforming a head-to-toe assessment on his patient with a history of mitral regurgitation. Instead of hearing normal heart sounds the student hears a murmur.

Which of the following best describes the sound of a heart murmur?