The nurse is preparing to auscultate for heart sounds on a client. Which of the following technique should be used by the nurse?
Listening for all possible sounds at a time at each specified area.
Listening to the sounds at the aortic, tricuspid, pulmonic, and mitral areas.
Listening to the sounds only at the site where the apical pulse is felt to be the strongest.
Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex.
The Correct Answer is D
A. Listening for all possible sounds at a time at each specified area: This approach does not allow for specific localization of different heart sounds and murmurs, making it difficult to accurately assess the heart's condition.
B. Listening to the sounds at the aortic, tricuspid, pulmonic, and mitral areas: This option is close but lacks the systematic approach of method D. Listening at specific anatomical locations (aortic, tricuspid, pulmonic, mitral) is important, but the Z pattern allows for thorough coverage and precise localization of any abnormal sounds.
C. Listening to the sounds only at the site where the apical pulse is felt to be the strongest: This method does not cover all the important auscultation sites on the heart and may miss significant findings.
D. Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex: This technique involves a systematic approach where the nurse listens at specific locations in a structured manner, ensuring comprehensive coverage of the heart sounds and murmurs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
In this sequence:
Vena cava brings deoxygenated blood from the body into the right atrium.
Blood flows from the right atrium to the right ventricle through the tricuspid valve.
The right ventricle pumps blood into the pulmonary artery to the lungs.
In the lungs, blood is oxygenated and returns to the heart via the pulmonary veins into the left atrium.
From the left atrium, blood moves to the left ventricle through the bicuspid (mitral) valve.
The left ventricle then pumps oxygenated blood into the body through the aorta.
This sequence represents the systemic and pulmonary circulation of the heart.
Correct Answer is {"dropdown-group-1":"C"}
Explanation
The pacemaker of the heart is known as the sinoatrial (SA) node. The SA node is a specialized group of cells located in the right atrium of the heart. It generates electrical impulses that initiate each heartbeat and set the rhythm for the entire heart.
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