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NUR 306 Midterm Question and answers verified to pass How does the nurse differentiate a pleural friction rub from a pericardial friction rub? A) Auscultate the upper back; if a rub is present, it is pleural B) Auscultate the base of the heart; if a rub is present, it is pericardial C) Turn...

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  • November 18, 2024
  • 67
  • 2024/2025
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NUR 306 Midterm Question and answers
verified to pass
How does the nurse differentiate a pleural friction rub from a pericardial
friction rub?


A) Auscultate the upper back; if a rub is present, it is pleural
B) Auscultate the base of the heart; if a rub is present, it is pericardial
C) Turn the client on the right side; if the rub persists, it is pericardial
D) Have the client hold his or her breath; if the rub persists, it is pericardial
D) Have the client hold his or her breath; if the rub persists, it is pericardial




We have an expert-written solution to this problem!
A student states that a client has a palpable rushing vibration in the area of
the pulmonic valve. What should the instructor explain that the student is
feeling?


A) A thrill
B) A normal finding
C) A heave
D) A thrust
A) a thrill


Rationale:
Thrills are vibrations detected on palpation. A palpable, rushing vibration
(thrill) is caused from turbulent blood flow with incompetent valves, pulmonary

,hypertension, or septal defects. This vibration is usually in the location of the
valve in which it is associated. A thrust or a heave is a forceful thrusting on the
chest. This is not a normal finding.




In order to palpate an apical pulse when performing a cardiac assessment,
where should the nurse place the fingers?


a. right of midclavicular line at the fifth intercostal space
b. right of the midclavicular line at the third intercostal space
c. left midclavicular line at the fifth intercostal space
d. left midclavicular line at the third intercostal space
c. left midclavicular line at the fifth intercostal space




Variations in the presentation of S1 are due to alterations in which heart
valve?


a. Pulmonic
b. Aortic
c. Tricuspid
d. Mitral
d. Mitral




The nurse's assessment of a client reveals jugular venous distention. The
nurse should conduct further assessments related to what health problem?

,a. Myocardial infarction
b. Peripheral arterial disease (PAD)
c. Heart failure
d. Venous thromboembolism
c. heart failure


Rationale:
Jugular venous distention (JVD) is associated with heart failure, tricuspid
regurgitation, and fluid volume overload. The neck veins appear full, and the
level of pulsation may be have elevated jugular venous pressure greater than
3 cm (about 1 1/4 in.) above the sternal angle. About 75% of patients with
elevated JVD have heart failure.




A nurse auscultates a client's heart sounds and notes an accentuated first
heart sound. The nurse would suspect which of the following?


a. Heart murmur
b. Mitral stenosis
c. Fever
d. Hypothyroidism
b. mitral stenosis


rationale:
An accentuated S1 sound louder than S2 occurs when the mitral valve is wide
open and closes quickly.

, The nurse is palpating in the right upper abdominal quadrant and feels an
enlarged area. The nurse recognizes that she is most likely feeling what
organ?


a. Pancreas
b. Liver
c. Gallbladder
d. Kidneys
b. liver




The should nurse assess for kidney tenderness at what location?


a. Costovertebral angle
b. Umbilical region
c. Hypogastric area
d. Midclavicular line
a. Costovertebral angle




To percuss the liver of an adult client, the nurse should begin the abdominal
assessment at the client's:


a. right lower quadrant
b. left lower quadrant
c. right upper quadrant
d. left upper quadrant

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