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 literacy is an important consideration, the focus should be on understanding the patient's cultural background to ensure appropriate care and address any specific needs related to their ethnicity and traditions.
B. A financial history may be relevant but does not directly relate to the patient's immediate care needs regarding abdominal pain.
C. Cultural assessment is essential to understand the patient's values, beliefs, and preferences in healthcare, particularly in a diverse population, to ensure culturally competent care.
D. Psychological history could be useful in some cases, but it is secondary to cultural considerations in a patient with abdominal pain.
Correct Answer is D
Explanation
Rationale
A. Pumping the cuff until no sound is heard may cause inaccurate readings and is not a proper technique.
B. Stopping midway can result in missing sounds or causing an inaccurate measurement.
C. The bell of the stethoscope should be used for low-pitched sounds, but the key is to continue listening to identify the full Korotkoff sound range, especially in the presence of an auscultatory gap.
D. It is important to continue listening until the cuff is deflated to ensure the accurate measurement of both systolic and diastolic pressures, particularly in patients with an auscultatory gap.
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