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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Fifth intercostal space, left of the midclavicular line: This placement is used to auscultate the mitral valve, which is best heard at the apex of the heart. The mitral valve sounds are typically heard around the fifth intercostal space, midclavicular line.

B. Left lower sternal border: This placement is used to auscultate the tricuspid valve, which is best heard at the lower left sternal border.

C. Second left intercostal space: This is the correct placement for auscultating the pulmonic valve. The pulmonic valve sounds are best heard at the second left intercostal space, which is close to the upper left sternal border.

D. Second right intercostal space: This placement is used to auscultate the aortic valve, which is best heard at the second right intercostal space, close to the upper right sternal border.

A. Friction rub B. Tactile fremitus C. Crepitus D. Adventitious sounds

Correct Answer is C

Explanation

A. Friction rub:

A friction rub is a grating or rubbing sound or sensation heard or felt during auscultation or palpation. It occurs when inflamed pleural or pericardial surfaces rub against each other during breathing or heartbeats, respectively.

B. Tactile fremitus:

Tactile fremitus refers to the palpable vibrations transmitted through the bronchopulmonary tree to the chest wall as the patient speaks. It is assessed by placing hands on the patient's back while the patient speaks certain words. Increased tactile fremitus can occur in conditions with lung consolidation, such as pneumonia.

C. Crepitus:

Crepitus is a crackling or grating sensation felt under the skin or heard when the ends of a broken bone rub against each other. It can also occur when air leaks into subcutaneous tissue, leading to a crackling sensation upon palpation.

D. Adventitious sounds:

Adventitious sounds refer to abnormal lung sounds heard during auscultation. These sounds include crackles (rales), wheezes, rhonchi, and pleural friction rubs. Adventitious sounds can indicate various respiratory conditions, such as pneumonia, bronchitis, or asthma.

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The nurse is preparing to auscultate for heart sounds on a client. Which of the following technique should be used by the nurse?

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Naxlex Comprehensive Predictor Exams

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