NURS 525 ASSESSMENT:
CARDIOVASCULAR - CE
, 1. The nurse is preparing to auscultate the B
patient's heart sounds. Which instruction
should the nurse give the patient? Auscultation requires the examiner to isolate
each heart sound at all sites without interfer-
A. "Say your name repeatedly."
ence from background noise such as talking.
B. "Breathe comfortably and refrain from The patient should be in a restful position.
speaking."
Taking deep breaths or holding respirations
C. "Walk in place and take deep breaths."
interferes with the nurse's ability to auscultate
D. "Bend the knees and hold your breath." heart sounds.
2. A patient complaining of palpitations is Intensity and pitch
admitted to the unit. The nurse auscul-
tates the patient's heart sounds and notes Intensity of a murmur is related to blood flow
a murmur. The nurse should assess which through the heart or the amount of blood
characteristics of the murmur? regurgitated. Pitch depends on the velocity of
blood flow through the valves.
3. When teaching a student nurse how to Upper left portion of the heart
auscultate the heart, the nurse correctly
explains that the base of the heart is lo- The base of the heart is in the upper left
cated in which area? portion of the heart; the bottom tip of the
heart is the apex. The base of the heart is not
located in the middle range or proximal side
of the heart. The student nurse must know this
because visualization improves the ability to
assess findings accurately and helps to deter-
mine the possible source of abnormalities.
4. A patient is complaining of swelling in 2+ edema
both feet. The nurse palpates the feet, and
the imprint of the nurse's finger remains An imprint that remains visible on the foot for
visible on the foot for 15 seconds. What 15 seconds is defined as grade 2+ edema.
Grade 1+ edema disappears rapidly. Grade
1/4
CARDIOVASCULAR - CE
, 1. The nurse is preparing to auscultate the B
patient's heart sounds. Which instruction
should the nurse give the patient? Auscultation requires the examiner to isolate
each heart sound at all sites without interfer-
A. "Say your name repeatedly."
ence from background noise such as talking.
B. "Breathe comfortably and refrain from The patient should be in a restful position.
speaking."
Taking deep breaths or holding respirations
C. "Walk in place and take deep breaths."
interferes with the nurse's ability to auscultate
D. "Bend the knees and hold your breath." heart sounds.
2. A patient complaining of palpitations is Intensity and pitch
admitted to the unit. The nurse auscul-
tates the patient's heart sounds and notes Intensity of a murmur is related to blood flow
a murmur. The nurse should assess which through the heart or the amount of blood
characteristics of the murmur? regurgitated. Pitch depends on the velocity of
blood flow through the valves.
3. When teaching a student nurse how to Upper left portion of the heart
auscultate the heart, the nurse correctly
explains that the base of the heart is lo- The base of the heart is in the upper left
cated in which area? portion of the heart; the bottom tip of the
heart is the apex. The base of the heart is not
located in the middle range or proximal side
of the heart. The student nurse must know this
because visualization improves the ability to
assess findings accurately and helps to deter-
mine the possible source of abnormalities.
4. A patient is complaining of swelling in 2+ edema
both feet. The nurse palpates the feet, and
the imprint of the nurse's finger remains An imprint that remains visible on the foot for
visible on the foot for 15 seconds. What 15 seconds is defined as grade 2+ edema.
Grade 1+ edema disappears rapidly. Grade
1/4
