Fundamentals CMS Midterm Questions and Answers

A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? A. Audible Click B. Murmur C. Third heart sound D. Pericardial friction rub Correct Ans - D) Pericardial friction rub A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following action should the nurse take? A. Auscultate for the blood presure at the dorsalis pedis artery. B. Measure the blood pressure with the client sitting on the side of the bed. C. Place the cuf f 7.6cm (3in) above the popliteal artery. D. Place the bladder of the cuf f over the posterior aspect of the thigh. Correct Ans - D) place the bladder of the cuf f over the posterior aspect of the thigh