The instructor asks the student nurse to auscultate the client's Erb's Point.
Where is the cardiac landmark referred to as the Erb's Point located?
5th ICS Left MCL.
3rd ICS Left SB.
2nd ICS Left SB.
4th ICS Left SB.
The Correct Answer is B
Choice A rationale
5th ICS Left MCL is the location for the apical impulse (point of maximal impulse), not Erb's Point.
Choice B rationale
Erb's Point is located at the 3rd ICS Left SB and is significant for auscultation of heart sounds, particularly the S1 and S2 sounds.
Choice C rationale
2nd ICS Left SB is the location for auscultating the pulmonic valve area.
Choice D rationale
4th ICS Left SB is where the tricuspid valve is auscultated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Functional incontinence occurs when an individual cannot reach the bathroom in time due to physical or cognitive limitations. It is not related to stress or pressure on the bladder but rather to external factors that impede timely access to toileting facilities.
Choice B rationale
Reflex incontinence is characterized by involuntary loss of urine due to a lack of signal awareness or detrusor muscle overactivity. It is typically associated with neurological conditions such as spinal cord injuries or multiple sclerosis. This type of incontinence does not involve stress-related triggers like coughing or sneezing.
Choice C rationale
Stress incontinence involves the involuntary leakage of urine during activities that increase intra-abdominal pressure, such as coughing, sneezing, laughing, or physical exertion. This type of incontinence is commonly seen in women, particularly after childbirth or during menopause, due to weakened pelvic floor muscles or sphincter dysfunction.
Choice D rationale
Urge incontinence is characterized by a sudden and intense urge to urinate, often resulting in involuntary urine leakage before reaching the bathroom. It is typically caused by overactive bladder muscles or nerve signals and is not specifically triggered by actions like coughing or sneezing.
Correct Answer is A
Explanation
Choice A rationale
Rhonchi are low-pitched, continuous breath sounds that are often indicative of secretions in the large airways. These sounds may change or clear with coughing, so the nurse should have the patient cough and then auscultate again to reassess the presence of rhonchi.
Choice B rationale
Wheezes are high-pitched, musical sounds heard primarily during expiration. They are caused by narrowed airways, typically due to asthma or other obstructive lung conditions. Wheezes do not usually clear with coughing and require specific treatments to address airway constriction.
Choice C rationale
Crackles are discontinuous, popping sounds heard during inspiration and are associated with fluid in the alveoli, such as in conditions like pneumonia or heart failure. Crackles are not typically cleared by coughing and may persist despite the patient's efforts to clear their airways.
Choice D rationale
Stridor is a high-pitched, harsh sound heard during inspiration, often indicating upper airway obstruction. Stridor is a medical emergency and requires immediate intervention to secure the airway. It does not clear with coughing and signifies a critical respiratory issue. .
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