Question

15. The nurse hears a swooshing sound that coincides with S1 while listening with the diaphragm of the stethoscope and becomes suspicious of the presence of a murmur. In order to assess Mr. Depodi completely, what action should the nurse take next?

            A. Document the findings and report the murmur to the charge nurse
            B. Repeat auscultation across the chest using the bell of the stethoscope
            C. Continue the assessment of heart sounds across the client's posterior thorax.
            D. Plan to repeat the assessment in one hour after the client rests

The nurse continues to assess Mr. Depodi and auscultates a low-pitched heart sound at the apical site with the bell of the stethoscope and determines an S3 sound can be heard.

16. What assessment must the nurse perform next?

            A. Check for jugular vein distention

            B. Note the onset of nail bed clubbing
            C. Check for diminished skin elasticity
            D. Assess for orthostatic hypotension

17. To inspect for jugular venous distension, what actions should the nurse take? (Select all that apply)

            A. Place the client in a Semi-Fowler's position with his head straight
            B. Lower the head of the bed while observing the neck veins
            C. Remove the client's pillow and turn his head away slightly
            D. Assist the client to lean forward at a 30-45 degree angle
            E. Place client in a semi-fowlers position

18. Continuing the neck assessment, how should the nurse begin a carotid artery assessment?

            A. Palpate one artery while listening to the other side with a stethoscope
            B. Palpate one artery and then palpate the artery on the opposite side
            C. Gently compress both arteries simultaneously to compare volume         

D. Avoid palpating and only use a stethoscope to listen to each artery

19. The nurse documents the findings and prepares to report the findings of Mr. Depodi’s assessment to the attending physician. Which assessment data is important to the nurse to report? (Select all that apply)

            A. Presence of S1 and S2 heart sounds
            B. Presence of S3 sound
            C. Observed jugular vein distention
            D. Noted absence of carotid bruit
            E. Client's subjective report of dyspnea

20. Important teaching points that Mr. Depodi would need to understand prior to being discharged would include all of the following except:

A. Taking short breaks when activity starts to cause chest discomfort.

B. Increasing caloric intake with meals.

C. How to check his own radial pulse at home.

D. Proper usage of nitroglycerin medication.

Answer 1

15)

B. Repeat auscultation across the chest using the bell of the stethoscope.

16)

A. Check for jugular vein distention.

17) To inspect for Jugular Vein distension :

A)Place the client in a Semi-Fowler's position with his head straight.

B)Lower the head of the bed while observing the neck veins.

C)Remove the client's pillow and turn his head away slightly

18)Palpation of Carotid artery.

B) Palpate one artery and then palpate the artery on the opposite side

19)

B. Presence of S3 sound.

C. Observed jugular vein distention

D. Noted absence of carotid bruit.

E. Client's subjective report of dyspnea

20)B. Increasing caloric intake with meals.