NURS3320-Assessing Heart & Neck Vessels exam -complete
1. While auscultating the client's heart at the third intercostal space and on the left sternal border, the nurse notes a high-pitched, scratchy sound that increa
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NURS3320-Assessing Heart & Neck Vessels exam -complete
1. While auscultating the client's heart at the third intercostal space and on the left sternal border, the nurse notes a high-pitched, scratchy sound that increases with exhalation with the client leaning forward. The nurse should document which of the following?
A) Pericardial friction rub
B) Midsystolic click
C) Summation gallop
D) Aortic ejection click
2. During chest auscultation, the nurse hears a quiet murmur immediately upon placing the stethoscope on the client's chest. The nurse interprets this as which grade?
A) 1
B) 2
C) 3
D) 4
3. A group of students is reviewing the structures of the heart, noting that the thickest layer of the heart is made up of contractile muscle cells. The students are correct in identifying this layer as which of the following?
A) Myocardium
B) Epicardium
C) Endocardium
D) Pericardium
4. A nurse is reviewing the electrical conduction system of the heart in preparation for assessing a client with a conduction problem. The nurse should be aware that the electrical signal originates in which of the following locations?
A) Bundle of His
B) Purkinje fibers
C) Sinoatrial node
D) AV node
5. The nurse is analyzing the data from the assessment of a client's heart and neck vessels. The client's first heart sound corresponds with what event in the cardiac cycle?
A) Isometric contraction
B) Closure of the semilunar valves
C) Beginning of diastole
D) Closure of the atrioventricular valves
6. The nurse is assessing a client who is in uncompensated right-sided heart failure. What assessment finding should the nurse anticipate?
CONTINUED......
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