A nurse is collecting data from a client who has mitral valve regurgitation. In which of the following areas should the nurse place the stethoscope to auscultate a murmur? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
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The Correct Answer is {"xRanges":[124.765625,154.765625],"yRanges":[96.609375,126.609375]}
{"A":{"choice":"-","reason":"
is not the correct answer because the tricuspid area is not the location where a nurse should auscultate for a murmur related to mitral valve regurgitation. The tricuspid area is located at the fifth intercostal space at the lower left sternal border, and is the site where blood flows from the right atrium to the right ventricle during systole.<\/p>"},"B":{"choice":"-","reason":"
The correct answer is choice B, the mitral area. When auscultating for a murmur in a client with mitral valve regurgitation, the nurse should place the stethoscope at the mitral area, which is the fifth intercostal space at the left midclavicular line. This is because the mitral valve is located at this spot and is the site where blood flows from the left atrium to the left ventricle during systole.<\/p>"},"C":{"choice":"-","reason":"
is not the correct answer because the aortic area is not the location where a nurse should auscultate for a murmur related to mitral valve regurgitation. The aortic area is found at the second intercostal space at the right sternal border, and is the site where blood flows from the left ventricle to the aorta during systole.
\r\nChoiceD4 is not the correct answer because the pulmonic area is not the location where a nurse should auscultate for a murmur related to mitral valve regurgitation. The pulmonic area is located at the second intercostal space at the
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\r\nleft sternal border, and is the site where blood flows from the right ventricle to the pulmonary artery during systole.<\/p>"},"D":{"choice":"-","reason":"
The correct answer is choice B, the mitral area. When auscultating for a murmur in a client with mitral valve regurgitation, the nurse should place the stethoscope at the mitral area, which is the fifth intercostal space at the left midclavicular line. This is because the mitral valve is located at this spot and is the site where blood flows from the left atrium to the left ventricle during systole.<\/p>"}}
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D, "I should adjust the TENS unit until I feel a tingling sensation." This is an appropriate statement that indicates the client understands how to use the TENS unit. The TENS unit works by sending electrical impulses to the nerves to block pain signals. The client should adjust the unit until they feel a tingling sensation, which is the desired effect.
"The TENS unit administers a continuous dose of pain medication" is not the correct answer because the TENS unit does not administer medication.
"I will need to charge the TENS unit for 2 hours each day" is not the correct answer because the TENS unit is battery operated and does not need to be charged.
"The TENS unit should be applied at least 6 inches from the actual site of my pain" is not the correct answer because the electrodes should be placed directly on the site of the pain.
Correct Answer is A
Explanation
The correct answer is: Choice A: Maintain direct pressure over the site.
Here's the rationale for each choice:
- Choice A: Maintain direct pressure over the site (CORRECT) This is the most important initial step in controlling bleeding for any patient, especially one with hemophilia who has a deficiency in clotting factors. Maintaining pressure directly on the wound helps to form a clot and stop the bleeding.
- Choice B: Check whether the bleeding has stopped While checking for bleeding cessation is important, it shouldn't be the immediate next step after applying a dressing. Maintaining pressure ensures the dressing remains effective. Once pressure is released, you can assess for continued bleeding.
- Choice C: Obtain a radial pulse Assessing the radial pulse is not directly related to managing the bleeding from the laceration. While it's a vital sign, it's not a priority in this situation.
- Choice D: Reinforce the dressing over the site While reinforcing the dressing might be necessary later if it becomes saturated with blood, maintaining direct pressure is the crucial first step.
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