During chest auscultation, the nurse hears a quiet murmur immediately upon placing the stethoscope on the client's chest. The nurse interprets this as which grade?
I
X
II
III
The Correct Answer is A
A. I: A grade I murmur is very faint and may not be heard immediately without careful listening. The description of a murmur heard immediately upon placing the stethoscope indicates it is a grade I.
B. X: There is no grade X in the standard grading scale for heart murmurs.
C. II: A grade II murmur is quiet but easily heard with a stethoscope and would generally be more audible than described.
D. III: A grade III murmur is moderately loud and would be heard without difficulty. The description suggests a quieter murmur.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E"]
Explanation
A. Caffeine intake: Can cause a temporary increase in blood pressure due to its stimulant effects.
B. Post meal: While eating can cause temporary changes in blood pressure, it is less likely to be a significant factor compared to other causes.
C. Stress: Can lead to temporary increases in blood pressure due to the body's stress response.
D. Drinking a glass of water: Typically does not significantly affect blood pressure unless there is an underlying issue such as dehydration.
E. Time of day: Blood pressure can naturally vary throughout the day, often being higher in the morning and lower in the evening.
Correct Answer is B
Explanation
A. S3: This sound is associated with early diastole, often related to heart failure or volume overload.
B. S1: The first heart sound (S1) marks the beginning of systole and corresponds to the closure of the mitral and tricuspid valves.
C. S2: The second heart sound (S2) indicates the end of systole and the beginning of diastole, associated with the closure of the aortic and pulmonic valves.
D. S4: This sound is associated with late diastole, often related to decreased ventricular compliance.
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