A nurse is assessing a client who has pericarditis.
In which of the following areas of the client's chest should the nurse place the stethoscope to best hear a pericardial friction rub? (You will find hot spots to select in the artwork below.
Select only the hot spot that corresponds to your answer.).
A
B
C
D
The Correct Answer is {"xRanges":[101.765625,141.765625],"yRanges":[263.609375,303.609375]}
A pericardial friction rub is highly specific for acute pericarditis and is generally heard over the left sternal border.
It is often louder at inspiration but sometimes can be better heard on forced expiration while the patient bends forward.
Choice A is not the answer because it does not correspond to the left sternal border.
Choice B is not the answer because it does not correspond to the left sternal border.
Choice D is not the answer because it does not correspond to the left sternal border.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
After inhaling deeply using an incentive spirometer, you should hold your breath for 3 to 5 seconds before exhaling.
Choice A is wrong because exhaling slowly through pursed lips is not an instruction for using an incentive spirometer.
Choice C is wrong because placing hands on the upper abdomen during inhalation is not an instruction for using an incentive spirometer.
Choice D is wrong because positioning the mouthpiece.5 cm (1 in) from the mouth is not an instruction for using an incentive spirometer.
Correct Answer is C
Explanation
The nurse should include this intervention in the plan of care because it can help relieve pressure on the reddened areas over the client’s bony prominences and prevent the development of pressure injuries.
Choice A is incorrect because applying an occlusive dressing to intact skin over bony prominences is not an appropriate intervention for preventing pressure injuries.
Choice B is incorrect because turning and repositioning the client every 4 hours may not be frequent enough to prevent the development of pressure injuries.
The client should be turned and repositioned more frequently, at least every 2 hours.
Choice D is incorrect because massaging reddened areas over bony prominences is not recommended as it can cause further damage to the skin and underlying tissues.
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