The nurse is assessing a patient whose chart indicates a Grade 3 ...

[KimWrice]

The nurse is assessing a patient whose chart indicates a Grade 3 heart murmur. What action is best in order to hear the murmur?
 
  a. Ensure that the room is extremely quiet.
  b. Use a specialized stethoscope with amplification.
  c. Auscultate the patient's chest with a stethoscope.
  d. Place the stethoscope diaphragm on the patient's back.

Question 2

A nurse observes a patient sitting up in bed, leaning forward with the arms braced against the over-the-bed table. What action by the nurse is best?
 
  a. Assess the patient for a barrel-chest appearance.
  b. Palpate the patient's abdomen for tenderness.
  c. Inspect the patient's spine for deformities.
  d. Ask the patient if he/she is experiencing dizziness.

[Jmfn03]

Answer to Question 1

ANS: C
A Grade 3 murmur should be readily heard with a regular stethoscope. Although the room should be quiet for all auscultation tasks, an extremely quiet room and an amplification stethoscope should not be necessary. The bell of the stethoscope is usually used to listen to heart murmurs, but the stethoscope needs to be on the patient's chest.

Answer to Question 2

ANS: A
This patient is sitting in a tripod position, often seen in patients with chronic obstructive pulmonary disease. These patients also often have a barrel-chest appearance, so the nurse assesses for this finding. The other actions are not related to a tripod position.