ANSWERS
What auscultating a client's heart sounds, the nurse hears a louder s2 when listening at the 2nd
intercostal space right sternal border. The nurse determines that is finding is consistent with the closure
of which heart valves? - CORRECT ANSWER✅✅Aortic and pulmonic
The second heart sound, "dub" or S2, is caused by the closure of the aortic and pulmonic valves, marking
the end of systole.
A nurse provides prevention strategies to a group of clients who are identified as at risk for
hypertension. Which strategies should the nurse include? - CORRECT ANSWER✅✅Walk briskly 30
minutes per day.
Choose foods like bananas and sweet potatoes. Use a low sodium seasoning to flavor food.
Which nursing assessment finding supports the diagnosis of chronic arterial insufficiency? - CORRECT
ANSWER✅✅Cool foot temperature and ulceration on the client's great toe
Pigmentation, medial ankle ulceration, and thickened, scarred skin are associated with venous
insufficiency, while low temperature and toe ulceration are more commonly found in cases of arterial
insufficiency.
When a patient is obese or has a thick chest wall, what is difficult to palpate? - CORRECT
ANSWER✅✅Apical Pulse
First attempt to palpate the apical pulse should be in supine position. If unable to feel it, place the
patient in the left lateral position.
What is the correct sequence of the cardiac examination? - CORRECT ANSWER✅✅Inspect the
pericardium, palpate pulses, then auscultation ( listen at the 2nd intercostal space.
, A nurse is palpating a patient's leg bilaterally with the back of her hands and notes that one leg is colder
than the other. The nurse knows that this may indicate which of the following? - CORRECT
ANSWER✅✅Inadequate arterial circulation
The nurse is assessing the jugular venous pressure (JVP) on a patient and notices that it measures at 9cm
from the sternal angle. The nurse knows that this may indicate which of the following? - CORRECT
ANSWER✅✅Right ventricular failure
RVF occurs when the right ventricle fails to maintain enough blood flow to the pulmonary circulation,
and blood begins backing up into the periphery. This would cause a bounding, or elevated JVP.
When a nurse is assessing the carotid pulse of a patient, the patient's head of bed should be elevated at
30 degrees - CORRECT ANSWER✅✅True
The nurse knows to listen for the S1 and S2 heart sounds in the supine position. However, if a nurse
suspects mitral stenosis, he/she should position the patient in which position to emphasize extra heart
sounds? - CORRECT ANSWER✅✅Left lateral position
(Place the bell of your stethoscope lightly on the apical impulse)
The nurse is performing the Allen test on a patient to compare the patency of the ulnar and radial
arteries. After compressing both arteries and releasing pressure over the ulnar artery, the nurse notes
continued pallor of the hand. The nurse knows that this indicates which of the following? - CORRECT
ANSWER✅✅Occlusion of the ulnar artery
(Remember that the radial artery continues to be compressed by the nurse.)
The nurse is preparing to percuss a patient's anterior chest area. Which approach will the nurse use for
this assessment? - CORRECT ANSWER✅✅Begin above the right clavicle and percuss each section
comparing the right chest with the left chest.
The nurse is preparing to auscultate the lung sounds of a young adult. Which soft, low pitched sound will
the nurse expect to har over most of the patient's lungs? - CORRECT ANSWER✅✅Vesicular