The sound of a slamming door
These create the heart sounds.
What are valves?
In preparing to perform a cardiovascular assessment, the nurse should initially place the client in which position?
What is sitting upright?
The nurse is percussing the seventh right intercostal space at the mid-clavicular line over the liver. Which sound should the nurse expect to hear?
A. Dullness
B. Tympany
C. Resonance
D. Hyperresonance
What is A?
Dullness should be heard where organs are
When palpating the abdomen of a 28-year-old patient, the nurse notices the presence of tenderness in the left upper quadrant with palpation. Which structure is most likely to be involved?
What is spleen?
The spleen is located in the left upper quadrant of the abdomen.
The nurse is performing percussion during an abdominal assessment. What percussion notes can be heard during an abdominal assessment?
What is tympany, hyperresonance, and dullness?
This valve makes the "lub" sound.
What is the tricuspid and mitral valves?
What is the apex?
The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment?
A. Examine the tender area first
B. Examine the tender area last
C. Avoid palpating the tender area
D. Palpate the tender area first, and then auscultate for bowel sounds
What is B?
The nurse should save the examination of any identified tender areas until last. This method avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the examination.
When palpating a patient, the patient reports tenderness to the right lower quadrant of abdomen. What organ could be involved?
What is appendix?
During an abdominal assessment, the nurse would consider which of these findings as expected?
A. Presence of bruit in the femoral area
B. Tympanic percussion note in the umbilical region
C. Palpable spleen between the ninth and eleventh ribs in the left mid-axillary line
D. Dull percussion note in the left upper quadrant at the mid-clavicular
What is B?
Tympanic percussion note in the umbilical region
This valve makes the "dub" sound.
What is the aortic and pulmonic valves?
The nurse is assessing a client who has a low-pitch murmur. What is the most appropriate way for the nurse to position the client to auscultate the murmur?
What is on the left lateral side using the bell of the stethoscope?
Put the assessment technique in order for an abdominal assessment.
What is inspect, auscultate, percuss, palpation?
Auscultation is performed before percussion and palpation because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds.
Which structure is located in the left lower quadrant of the abdomen?
What is Sigmoid colon?
Which of the following complications is indicated by a third heart sound (S3)?
A. Ventricular dilation
B. Systemic hypertension
C. Aortic valve malfunction
D. Increased atrial contractions
What is A?
Rapid filling of the ventricle causes vasodilation that is auscultated as S3.
The right ventricle pushes blood through this valve.
What is the pulmonic valve?
The nurse is assessing a patient for heart sounds, which of the following is the most accurate?
A. S1 is louder than S2 at the base
B. S2 is louder than S1 at the apex
C. S1 coincides with the carotid artery pulse
D. S2 coincides with the R wave if the person is on an EKG monitor.
What is C?
S1 is louder at the apex and S2 is louder at the base. The pulse you feel when assessing the carotid is S1 sound. S1 coincides with the R wave, not S2.
The nurse knows that during an abdominal assessment, deep palpation is used to determine:
A. Bowel motility
B. Enlarged organs
C. Superficial tenderness
D. Overall impression of skin surface and superficial musculature
What is presence of enlarged organs?
What structures are in the right upper quadrant?
What is liver, gallbladder, pancreas, duodenum, right kidney, part of the ascending and transverse colon, small part of stomach, right adrenal gland?
Which of the following cardiac conditions does a fourth heart sound (S4) indicate?
A. Dilated aorta
B. Normally functioning heart
C. Decreased myocardial contractility
D. Failure of the ventricle to eject all of the blood during systole
What is D?
An S4 occurs as a result of increased resistance to ventricular filling after atrial contraction. The increased resistance is related to decreased compliance of the ventricle. A dilated aorta doesn't cause an extra heart sound, though it does cause a murmur. Decreased myocardial contractility is heard as a third heart sound. An S4 isn't heard in a normally functioning heart.
The left ventricle pushes blood through this valve.
What is the aortic valve?
Name the landmarks for aortic valve, pulmonic valve, tricuspid valve, and mitral valve.
What is:
second right intercostal space- Aortic
second left intercostal space- Pulmonic
Left lower sternal border- Tricuspid valve
Fifth intercostal at left midclavicular line- Mitral valve
During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as absent bowel sounds, the nurse should listen for at least:
A. 1 minute
B. 5 minutes
C. 10 minutes
D. 2 minutes in each quadrant
What is B?
5 minutes is the appropriate time.
A patient is complaining of a sharp pain along the costovertebral angles. The nurse is aware that this symptom is most often indicative of:
A. Gallbladder inflammation
B. Liver enlargement
C. Kidney inflammation
D. Spleen enlargement
What is C?
Kidney inflammation
The nurse is auscultating bowel sounds. Which of the following states is TRUE about bowel sounds?
A. Usually loud, high-pitched, rushing, and tinkling sound
B. Usually high-pitched, gurgling and irregular sounds
C. Sound like two pieces of leather being rubbed together
D. Originate from the movement of air and fluid through the large intestine
What is B?
High-pitched, gurgling, and irregular sounds