The nurse detects a possible extra heart sound while assessing an adult client. To verify this finding, which action should the nurse take?

Listen to the heart sounds using the bell of a stethoscope.

Use a Doppler ultrasound to hear the heartbeat.

Obtain a pulse oximeter reading from two extremities.

Auscultate for one minute with the stethoscope's diaphragm.

Answer and Explanation

The Correct Answer is A

A.   The bell of the stethoscope is best for detecting low-pitched sounds like murmurs or extra heart sounds.
B.   A Doppler ultrasound is not necessary for routine auscultation of heart sounds.
C.   Pulse oximetry does not provide relevant information about heart sounds.
D.   Auscultating with the diaphragm is better for high-pitched sounds, so the bell is preferred for extra heart sounds.

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Correct Answer is ["B","C","D","E"]

Explanation

A. Documenting the roaring and crackles is important to note any abnormal findings. However, this does not directly mitigate artifacts, which may interfere with the accuracy of the sounds heard through auscultation.
B. Wetting the chest hair is a useful technique to reduce the sound interference caused by chest hair rubbing against the stethoscope. This helps eliminate some of the unwanted sounds and improves the clarity of auscultation.
C. Ensuring the room is warm and the stethoscope is warmed before use is important because cold stethoscopes can cause discomfort to the client and may lead to muscle tensing, making it harder to hear clear heart and lung sounds.
D. Reaching under the gown ensures that no clothing creates friction on the stethoscope, which can produce unwanted sounds during auscultation. This helps in obtaining clear and accurate heart or lung sounds.
E. A quiet environment is crucial for auscultation, as background noise can obscure important sounds. Ensuring that the room is free from distractions and noise will significantly improve the quality of auscultation.

A. Anal mucosa prolapse and loose sphincter tone. B. Dried dark red blood on swollen external hemorrhoids. C. Serosanguineous and purulent exudate from anus. D. Tears of the anal mucosa with old blood around anus.

Correct Answer is B

Explanation

A. Anal mucosa prolapse may be a concern but would not explain the appearance of the dark red blood and external hemorrhoidal mass.
B. Dried, dark red blood on swollen external hemorrhoids suggests hemorrhoidal bleeding, which is common and associated with the appearance of a purple, shiny tissue mass.
C. Serosanguineous or purulent exudate suggests infection or other concerns but does not fit the description of the observed finding in this case.
D. Tears in the anal mucosa with old blood may occur, but they are not as likely to present as a shiny, purple mass with dark red blood on the surface.

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The nurse detects a possible extra heart sound while assessing an adult client. To verify this finding, which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits Nurse analyzes the findings. Which can the nurse do to mitigate artifacts when performing auscultation? Select all that apply.

Correct Answer is ["B","C","D","E"]

Explanation

Correct Answer is B

Explanation

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