The nurse auscultates a systolic murmur in the second intercostal space to the right of the sternum while performing a cardiac assessment on a client. The nurse interprets this finding as:

An occlusion of the right coronary artery

An aneurysm of the descending aorta

Decreased fluid in the pericardial sac

Distortion of one or more heart valves

Answer and Explanation

The Correct Answer is D

Choice A reason: This is not a correct interpretation. An occlusion of the right coronary artery is a blockage of the blood flow to the right side of the heart, which can cause a heart attack or ischemia. This condition does not produce a systolic murmur, but rather chest pain, shortness of breath, sweating, or nausea. A systolic murmur is a sound that occurs during the contraction of the heart, when the blood flows through a narrowed or leaky valve.

Choice B reason: This is not a correct interpretation. An aneurysm of the descending aorta is a bulging or weakening of the wall of the large artery that carries blood from the heart to the lower body. This condition does not produce a systolic murmur, but rather a pulsating mass in the abdomen, back pain, or abdominal pain. A systolic murmur is a sound that occurs during the contraction of the heart, when the blood flows through a narrowed or leaky valve.

Choice C reason: This is not a correct interpretation. Decreased fluid in the pericardial sac is a condition where the amount of fluid that surrounds and cushions the heart is reduced. This can be caused by dehydration, infection, or inflammation. This condition does not produce a systolic murmur, but rather a pericardial friction rub, which is a scratching or grating sound that occurs when the layers of the pericardium rub against each other. A systolic murmur is a sound that occurs during the contraction of the heart, when the blood flows through a narrowed or leaky valve.

Choice D reason: This is the correct interpretation. Distortion of one or more heart valves is a condition where the shape or function of the valves that regulate the blood flow through the heart is altered. This can be caused by congenital defects, rheumatic fever, endocarditis, or aging. This condition can produce a systolic murmur, which is a sound that occurs during the contraction of the heart, when the blood flows through a narrowed or leaky valve. The location and the intensity of the murmur can help identify which valve is affected. A systolic murmur in the second intercostal space to the right of the sternum can indicate a problem with the aortic valve.

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Correct Answer is D

No explanation

A. have a urinary output of greater than 30 mL per hour for 24 hours. B. discuss which lifestyle modifications will be necessary to maintain health. C. express no complaints of chest discomfort or shortness of breath. D. have clear breath sounds bilaterally upon auscultation.

Correct Answer is C

Explanation

Choice A reason: Having a urinary output of greater than 30 mL per hour for 24 hours is not the most appropriate outcome for the problem of impaired tissue perfusion. This outcome is more relevant for the problem of fluid volume excess or renal impairment, which are not the case for this client.

Choice B reason: Discussing which lifestyle modifications will be necessary to maintain health is not the most appropriate outcome for the problem of impaired tissue perfusion. This outcome is more relevant for the problem of knowledge deficit or risk for recurrence, which are not the priority for this client.

Choice C reason: Expressing no complaints of chest discomfort or shortness of breath is the most appropriate outcome for the problem of impaired tissue perfusion. This outcome indicates that the client's cardiac output and oxygen delivery are adequate and that the interventions are effective.

Choice D reason: Having clear breath sounds bilaterally upon auscultation is not the most appropriate outcome for the problem of impaired tissue perfusion. This outcome is more relevant for the problem of impaired gas exchange or pulmonary congestion, which are not the case for this client.

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The nurse auscultates a systolic murmur in the second intercostal space to the right of the sternum while performing a cardiac assessment on a client. The nurse interprets this finding as:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has chronic stable angina is being discharged. Which statement by the client indicates an understanding of the discharge teaching?

Correct Answer is D

The nurse, who is caring for a client diagnosed with coronary artery disease, prioritizes the problem of impaired tissue perfusion in the plan of care. Which outcome would be most appropriate? The client will:

Correct Answer is C

Explanation

The nurse recognizes that the rationale for the medical prescription of aspirin 81 mg PO daily and clopidogrel 75 mg PO daily for the client with coronary artery disease is that these medications:

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