While auscultating heart sounds, the nurse hears a murmur. Which of these instruments should be used to assess this murmur?
a. Electrocardiogram
b. Bell of the stethoscope
c. Diaphragm of the stethoscope
d. Palpation with the nurse's palm of the hand
ANS: B
The bell of the stethoscope is best for soft, low-pitched sounds such as extra heart sounds or murmurs. The diaphragm of the stethoscope is best used for high-pitched sounds such as breath, bowel, and normal heart sounds.
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The nurse applies a heat pack to the leg of an older adult diabetic client and finds first- and second-degree burns when the pack is discontinued. Place the nurse's priority actions in the proper order of performance
Click on the down arrow for each response in the right column and select the correct choice from the list Response 1. Complete an incident form. Response 2. Notify the nurse in charge. Response 3. Assess the client. Response 4. Provide analgesia as needed if an order exists. Response 5. Document the treatment and outcome.
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a. Prone b. Supine c. Left side-lying d. Right side-lying