The nurse is informed that a patient had abnormal heart sounds during the night shift. When auscultating abnormal heart sounds, the nurse knows to listen to heart sounds with the:
bell of the stethoscope on top of the patient's gown.
diaphragm of the stethoscope directly on the patient's skin.
diaphragm of the stethoscope on top of the patient's gown.
bell of the stethoscope directly on the patient's skin.
The Correct Answer is B
A. The bell is used to detect low-pitched sounds, but abnormal heart sounds are often high-pitched, requiring the diaphragm.
B. The diaphragm of the stethoscope is best for detecting high-pitched heart sounds, such as murmurs or abnormal rhythms.
C. The diaphragm on top of the gown would create interference and prevent proper auscultation of heart sounds.
D. The bell is used for lower-pitched sounds and is not the best choice for auscultating abnormal heart sounds.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Pushing the soles of the feet against the nurse's hands is a standard test to assess the strength of the lower extremities. It provides a clear indication of muscular strength and motor function.
B. Wiggling toes helps assess for sensation but does not evaluate overall strength or motor function in the lower extremities.
C. Pulling both feet up to stretch the Achilles tendons is not an appropriate method for assessing lower extremity strength.
D. Standing independently does not evaluate strength comprehensively and is more related to balance and coordination.
Correct Answer is B
Explanation
A. Dehydration causes a drop in circulating blood volume, which can lead to lower blood pressure, not muffled sounds.
B. When a person is dehydrated, there is less fluid in the bloodstream, which typically causes a decrease in blood pressure.
C. Blood pressure is likely to decrease in dehydration due to reduced circulating volume, rather than remain unchanged.
D. Dehydration will not increase blood pressure; it typically causes a compensatory decrease in blood pressure.
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