during auscultation of a patients heart sounds the nurse hears an unfamiliar sound which action would the nurse take

NCLEX-RN

NCLEX RN Predictor Exam

1. During auscultation of a patient's heart sounds, the nurse hears an unfamiliar sound. Which action would the nurse take?

A. Ask the patient how he or she is feeling.
B. Document the findings in the patient's record.
C. Wait 10 minutes and auscultate the sound again.
D. Ask another nurse to double-check the finding.

Correct answer: D

Rationale: When encountering an unfamiliar sound during auscultation, it is crucial for the nurse to seek confirmation from another healthcare professional. Asking the patient about their feelings may not provide insight into the unfamiliar sound. Simply documenting the findings without verification may lead to errors in interpretation. Waiting and auscultating again after 10 minutes might delay necessary intervention. Consulting another nurse for a second opinion ensures accurate identification of the unfamiliar sound and appropriate follow-up actions.

2. A healthcare professional realizes after a patient has left the office that they forgot to document the patient's complaint of a sore throat. Which of the following choices would BEST correct the error?

A. Pull out that page of the chart and rewrite it with the correct information.
B. Put one line through the original Chief Complaint, write 'ERROR,' your initials, and today's date. Make the correction by rewriting the Chief Complaint with the correct information.
C. Go to the next available line of the SOAP notes. Write the current date, then write 'Late Entry.' Place the date and time when the patient stated they had a sore throat. Sign and date the entry.
D. All of the above are incorrect.

Correct answer: C

Rationale: When adding information to a patient's chart after the encounter, using the term 'Late Entry' is essential. This clearly indicates that the information was added after the fact and helps to maintain the accuracy and integrity of the medical record. Option A is incorrect because removing a page from the chart and rewriting it can lead to inaccuracies and is not a recommended practice for correcting errors. Option B suggests marking the original Chief Complaint as an error, which may not be clear to future readers of the chart and could lead to confusion. Option D is incorrect as it dismisses the correct approach outlined in Option C, which is the best way to handle the situation of missed documentation during a patient encounter.

3. What are Korotkoff sounds?

A. Sounds noted during diastole.
B. The result of the vibration of blood against artery walls while blood pressure readings are being taken.
C. Sounds only noted by skilled cardiologists.
D. Distinct sounds which are classified into 6 phases.

Correct answer: B

Rationale: Korotkoff sounds are the sounds that occur when blood flows in an artery that has been temporarily compressed during a blood pressure measurement. These sounds result from the vibration of blood against the artery walls as the pressure cuff is released. There are five distinct phases of Korotkoff sounds, which healthcare providers are trained to identify during blood pressure assessment. The correct answer, choice B, accurately describes the nature of Korotkoff sounds and how they are generated. Choices A, C, and D are incorrect because Korotkoff sounds are not specific to diastole, not limited to skilled cardiologists, and categorized into five phases, not six.

4. When checking for proper blood pressure cuff size, which guideline is correct?

A. The standard cuff size is appropriate for all sizes.
B. The length of the rubber bladder should equal 80% of the arm circumference.
C. The width of the rubber bladder should equal 80% of the arm circumference.
D. The width of the rubber bladder should equal 40% of the arm circumference.

Correct answer: D

Rationale: When selecting the correct blood pressure cuff size, it is essential to ensure that the width of the rubber bladder equals 40% of the circumference of the person's arm. This ensures proper fitting and accurate readings. The length of the bladder should actually equal 80% of the arm circumference, not 80% of the width, making choices B and C incorrect. Choice A stating that the standard cuff size is appropriate for all sizes is inaccurate, as using an incorrectly sized cuff can lead to inaccurate blood pressure readings.

5. Which of the following is an example of emotional neglect?

A. A slap to the person's hand
B. Threatening the person
C. Ignoring and isolating a person
D. Leaving a patient soiled for hours

Correct answer: C

Rationale: The correct answer is ignoring and isolating a person. Emotional neglect involves failing to meet the emotional needs of individuals, which can include ignoring their feelings and isolating them. Choices A, B, and D involve physical aggression, verbal threats, and neglect of physical care, respectively. These actions may be forms of abuse or neglect, but they do not specifically relate to emotional neglect as described in the question.