Assessment, Heart and Neck Vessel
Examination, Auscultation of Heart Sounds,
Murmurs, S1 S2 S3 S4, Apical Impulse,
Jugular Venous Pressure, Electrical
Conduction System, Coronary Artery Disease
Risk Factors, Heart Failure, Mitral
Insufficiency, Cardiac Cycle, Blood Pressure,
Pulse Assessment, Electrocardiogram
Interpretation, Health Promotion, Patient
Education, COLDSPA Chest Pain Assessment,
Community Health, Cardiac Physiology,
Clinical Nursing Skills, Cardiac
Pathophysiology, Nursing Interventions,
NCLEX High-Yield Review Exam Questions
Verified and Provided with A+ Graded
Rationales Latest Updated 2026
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
A) Pericardial friction rub
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
B) 2
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
A) Myocardium
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
C) Sinoatrial 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
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?
A) Increased jugular venous pressure
B) Bradycardia
C) Decreased blood pressure
D) Dysrhythmias
A) Increased jugular venous pressure