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","D"]
Explanation
A. Using low sodium seasoning can help reduce sodium intake, which is beneficial for hypertension management.
B. Increasing dairy products may not necessarily help with hypertension unless they are low-fat or fat-free options, but it’s not a primary strategy.
C. Foods like bananas and sweet potatoes are high in potassium, which helps counteract sodium's effects and supports healthy blood pressure.
D. Brisk walking for 30 minutes per day is a recommended exercise to help manage and prevent hypertension.
E. Consuming red wine is not recommended for hypertension; excessive alcohol intake can increase blood pressure.
Correct Answer is A
Explanation
A. Palpating McBurney's point for rebound tenderness helps evaluate for appendicitis, which is relevant given the client’s localized tenderness in the right lower quadrant.
B. Murphy's sign is used to assess for gallbladder inflammation, which is not indicated by right lower quadrant pain.
C. The Tinel sign is used to assess for nerve irritation, not abdominal pain or appendicitis.
D. Testing for a fluid wave is used to assess for ascites, which does not fit the presentation of localized right lower quadrant pain.
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