The nurse collects data for a client who is diagnosed with mitral stenosis with a murmur. In which position does the nurse place the client to auscultate the documented murmur?

Left lateral

Right lateral

Prone

Supine

Answer and Explanation

The Correct Answer is A

A. Left lateral: Placing the client in the left lateral decubitus position brings the heart closer to the chest wall, especially the mitral valve. This position enhances the nurse’s ability to hear low-pitched diastolic murmurs like those associated with mitral stenosis.
B. Right lateral: This position does not improve the ability to hear mitral valve sounds. It moves the heart further from the chest wall and is not used for cardiac auscultation purposes.
C. Prone: A prone position is not used for heart assessments and may interfere with effective auscultation. It compresses the chest and limits access to key valve areas.
D. Supine: While commonly used for initial heart assessments, it may not be ideal for detecting low-frequency murmurs. Certain murmurs become more audible when the client is in a specific position, such as the left lateral for mitral stenosis.

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Correct Answer is B

Explanation

A. Shift of rib cage toward affected side: The rib cage does not typically shift in tension pneumothorax. Instead, the thorax on the affected side may appear hyperinflated or fixed in inspiration but does not physically shift toward the affected side.
B. Shift of trachea, esophagus, heart, and great vessels: A tension pneumothorax can cause increased intrathoracic pressure, pushing the mediastinal structures toward the unaffected side. This mediastinal shift is a critical sign and can lead to impaired cardiac output and respiratory collapse.
C. Fluctuation of the fluid in the water-seal chamber: This is an expected finding in a chest tube system and indicates proper function. It does not reflect a mediastinal shift and is not specific to tension pneumothorax.
D. Sucking sound heard on inspiration and expiration: This is more commonly associated with an open pneumothorax, not a tension pneumothorax. Tension pneumothorax involves air trapping without an external opening.

A. Advise the client to void while lying flat with a urinal. B. Encourage the client to drink fluids. C. Evaluate the client's temperature. D. Monitor the client's pressure dressing.

Correct Answer is D

Explanation

A. Advise the client to void while lying flat with a urinal: While voiding in a supine position is often necessary to maintain hemostasis, it is not the top priority. It is a supportive measure that follows after ensuring vascular integrity.
B. Encourage the client to drink fluids: Hydration helps flush contrast dye from the kidneys and is important, but it is a secondary priority. Bleeding at the catheter insertion site requires more immediate attention post-procedure.
C. Evaluate the client's temperature: Monitoring temperature may detect late signs of infection, but it is not a critical concern in the immediate post-catheterization period unless there are signs of systemic illness.
D. Monitor the client's pressure dressing: Bleeding or hematoma formation at the catheter insertion site (often the femoral artery) is a major concern. Frequent monitoring of the pressure dressing is essential to detect and manage hemorrhage early, making it the top priority.

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The nurse collects data for a client who is diagnosed with mitral stenosis with a murmur. In which position does the nurse place the client to auscultate the documented murmur?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with tension pneumothorax. Which nursing assessment would alert the nurse to the development of a mediastinal shift in this client?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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