ATI Learning System RN 3.0 Fundamentals 1 Latest 2024 100% Pass

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? - Audible click - Murmur - Third heart sound - Pericardial friction rub Pericardial friction rub: A pericardial friction rub has a high-pitched scratching, grating, or squeaking leathery sound heard best with the diaphragm of the stethoscope at the left sternal border. A pericardial friction rub is a manifestation of pericardial inflammation and can be heard with infective pericarditis with myocardial infarction, following cardiac surgery or trauma, and with some autoimmune problems, such as rheumatic fever. The client who develops pericarditis typically has chest pain which becomes worse with inspiration or coughing and which may be relieved by sitting up and leaning forward. A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? - Auscultate for the blood pressure at the dorsalis pedis artery. - Measure the blood pressure with the client sitting on the side of the bed. - Place the cuff 7.6 cm (3 in) above the popliteal artery. - Place the bladder of the cuff over the posterior aspect of the thigh. Place the bladder of the cuff over the posterior aspect of the thigh. This is the correct position for the nurse to place the bladder of the cuff when measuring a lower extremity blood pressure.