The nurse prepares to begin a systematic assessment of a client's heart sounds. Upon positioning the stethoscope as seen in the picture, which should the nurse do first?
Listen for abnormal sounds.
Identify S1 and S2 heart sounds.
Move the stethoscope to the apical site.
Change to the bell of the stethoscope.
The Correct Answer is B
A. Listen for abnormal sounds. Before identifying abnormal sounds, it's essential to first establish a baseline by identifying the normal heart sounds (S1 and S2).
B. Identify S1 and S2 heart sounds. This is the correct first step in a systematic assessment of heart sounds. S1 ("lub") corresponds to the closure of the atrioventricular valves (mitral and tricuspid), while S2 ("dub") corresponds to the closure of the semilunar valves (aortic and pulmonic).
C. Move the stethoscope to the apical site. While the apical site is important for auscultating specific heart sounds, it's best to first identify S1 and S2 at the traditional auscultatory areas (aortic, pulmonic, tricuspid, and mitral).
D. Change to the bell of the stethoscope. The bell of the stethoscope is used to listen for lower-pitched sounds, but it's not typically used for identifying S1 and S2 heart sounds, which are higher-pitched.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Listen for abnormal sounds. Before identifying abnormal sounds, it's essential to first establish a baseline by identifying the normal heart sounds (S1 and S2).
B. Identify S1 and S2 heart sounds. This is the correct first step in a systematic assessment of heart sounds. S1 ("lub") corresponds to the closure of the atrioventricular valves (mitral and tricuspid), while S2 ("dub") corresponds to the closure of the semilunar valves (aortic and pulmonic).
C. Move the stethoscope to the apical site. While the apical site is important for auscultating specific heart sounds, it's best to first identify S1 and S2 at the traditional auscultatory areas (aortic, pulmonic, tricuspid, and mitral).
D. Change to the bell of the stethoscope. The bell of the stethoscope is used to listen for lower-pitched sounds, but it's not typically used for identifying S1 and S2 heart sounds, which are higher-pitched.
Correct Answer is B
Explanation
A. Offer the child bubbles before the stethoscope is placed. Blowing bubbles can help distract the child and make them more relaxed, but it may not be as effective as involving the child directly in the process.
B. Allow the child to use a stethoscope on a stuffed animal. This is an effective approach as it involves the child in the process, making them more comfortable and cooperative. It helps demystify the stethoscope and can reduce fear or anxiety.
C. Place a toy in the child's hands while listening to the breath sounds. Holding a toy can be distracting and help keep the child still, but it does not directly involve the child in the assessment process as effectively as letting them use the stethoscope.
D. Have the child blow a cotton ball and have the parent catch it. Blowing a cotton ball can help with deep breathing, which is useful for lung auscultation. However, it may not ensure the child's cooperation throughout the entire assessment as effectively as option B.
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