The nurse completes auscultation of the heart on an older adult client. Which finding is considered normal for this client?

Murmurs.

Absent sounds.

No adventious sounds.

Adventious sounds.

Answer and Explanation

The Correct Answer is A

A. Murmurs can be a normal finding in older adults due to age-related changes in the heart valves or blood flow. They are not necessarily indicative of pathology if they are not associated with symptoms or changes in the client's condition.

B. Absent heart sounds would be abnormal and could indicate severe underlying issues such as cardiac arrest or severe hypovolemia.

C. While no adventitious sounds are generally expected, the presence of murmurs is considered normal in this age group.

D. Adventitious sounds (such as crackles or wheezes) are not normal in heart auscultation and would suggest potential pathologies.

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Correct Answer is C

Explanation

A. Inserting a urinary catheter is a skill that typically requires a licensed nurse's expertise.

B. Titrating oxygen requires assessment and adjustment based on clinical findings, which is outside the UAP’s scope of practice.

C. Procuring platelet products from the blood bank is a non-clinical task that can be safely assigned to a UAP.

D. Monitoring an IV infusion rate involves clinical judgment and is typically performed by a licensed nurse.

A. A resting respiratory rate of 35 breaths/minute. B. Flaring of the nares. C. Diaphragmatic respirations. D. Bilateral bronchial breath sounds.

Correct Answer is B

Explanation

A. A respiratory rate of 35 breaths/minute can be normal for a 2-year-old, so it is not necessarily indicative of distress by itself.

B. Flaring of the nares is a sign of increased work of breathing and is an indication of respiratory distress, as the child is using accessory muscles to breathe.

C. Diaphragmatic respirations are typical for young children and not indicative of distress unless other signs are present.

D. Bilateral bronchial breath sounds do not necessarily indicate respiratory distress and could be normal depending on the context.

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The nurse completes auscultation of the heart on an older adult client. Which finding is considered normal for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to an unlicensed assistive personnel (UAP)?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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