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 C
Explanation
A. While extremity inspection is important, it is not as directly related to assessing back pain as evaluating the back itself.
B. Auscultating the lungs is essential in respiratory assessments but is not the priority when examining a patient with back pain.
C. Percussion of the flank areas is a key part of the physical examination for back pain, particularly if there are concerns of kidney involvement or other internal issues causing discomfort.
D. Bowel sounds are not directly related to back pain unless gastrointestinal issues are suspected.
Correct Answer is B
Explanation
A. Kussmaul's respirations are rapid, deep, and labored breaths often seen in metabolic acidosis, which does not match the pattern described.
B. Cheyne-Stokes respirations are characterized by a pattern of deep and fast breathing followed by periods of apnea. This pattern is seen in patients with severe conditions like heart failure or brain injury.
C. Biot's respirations are irregular, but the cycle does not have a distinct pattern of fast, slow, and apnea periods.
D. Hyperventilation refers to an increased rate of breathing but does not involve the cycles of deep, slow, and apneic phases characteristic of Cheyne-Stokes.
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