Author Question: A registered nurse (RN) is observing a student nurse who is doing a physical assessment on a ... (Read 111 times)

LCritchfi · **on:** Jun 25, 2018

A registered nurse (RN) is observing a student nurse who is doing a physical assessment on a pa-tient. The RN will need to intervene immediately if the student nurse

a. presses on the skin over the tibia for 10 seconds to check for edema.
b. palpates both carotid arteries simultane-ously to compare pulse quality.
c. documents a murmur heard along the right sternal border as a pulmonic murmur.
d. places the patient in the left lateral posi-tion to check for the point of maximal impulse.

Question 2

The nurse hears a murmur between the S1 and S2 heart sounds at the patient's left fifth inter-costal space and midclavicular line. How will the nurse record this information?

a. Systolic murmur heard at mitral area
b. Systolic murmur heard at Erb's point
c. Diastolic murmur heard at aortic area
d. Diastolic murmur heard at the point of maximal impulse

diesoon · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: B
The carotid pulses should never be palpated at the same time to avoid vagal stimulation, dysrhythmias, and decreased cerebral blood flow. The other assessment techniques also need to be corrected. However, they are not dangerous to the patient.

Answer to Question 2

ANS: A
The S1 signifies the onset of ventricular systole. S2 signifies the onset of diastole. A murmur oc-curring between these two sounds is a systolic murmur. The mitral area is the intersection of the left fifth intercostal space and the midclavicular line. The other responses describe murmurs heard at different landmarks on the chest and/or during the diastolic phase of the cardiac cycle.