The nurse is assessing a new admission and hears a murmur at the second left intercostal space along the left sternal border. The nurse anticipates the client has a murmur of which valve?

Pulmonic

Aortic

Tricuspid

Mitral

Answer and Explanation

The Correct Answer is A

A. Pulmonic: The pulmonic valve is best auscultated at the second left intercostal space along the left sternal border. A murmur heard in this location is most likely associated with pulmonic valve abnormalities such as pulmonary stenosis or pulmonary regurgitation.

B. Aortic: The aortic valve is auscultated at the second right intercostal space at the right sternal border. A murmur at this site may indicate aortic stenosis or regurgitation, but not when heard on the left side as in this scenario.

C. Tricuspid: Tricuspid valve murmurs are typically heard best at the lower left sternal border, around the fourth or fifth intercostal space. This location is more inferior than where the nurse auscultated the murmur in the current assessment.

D. Mitral: The mitral valve is best heard at the fifth intercostal space at the midclavicular line (the cardiac apex). Murmurs related to mitral stenosis or regurgitation would not typically be heard at the second intercostal space near the sternum.

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Correct Answer is D

Explanation

A. Blood pressure reading of 120/80: While a normal blood pressure is desirable, this value alone does not indicate improvement in fluid overload or pulmonary symptoms. It may remain normal even if respiratory status worsens or fails to improve.

B. Urine output 30 mL for one hour: Although urine output is an important measure of diuretic effectiveness, 30 mL/hr is the minimum acceptable rate, not necessarily a strong indicator of clinical improvement. More robust diuresis may be expected following IV furosemide.

C. Serum sodium level is 135 mEq/L (135–145): A normal sodium level reflects stable electrolyte status but does not directly indicate improvement in pulmonary congestion or dyspnea. Sodium may be affected by many factors unrelated to heart failure symptom relief.

D. Respiratory rate 16 per minute: A decrease in respiratory rate from 26 to 16 suggests improved oxygenation, reduced pulmonary congestion, and decreased work of breathing. It is the most direct and clinically relevant indicator of symptomatic improvement in this context.

A. contact the prescriber to decrease the rate of the D51/2 NS during the blood transfusion B. stop the D51/2NS, check the client's vitals & notify the prescriber. C. Fluids cannot be given through a CVC. D. Insert a 22 gauge peripheral IV to administer the transfusion E. transfuse the unit of packed red blood cells through a separate lumen of the CVC

Correct Answer is E

Explanation

A. contact the prescriber to decrease the rate of the D51/2NS during the blood transfusion: There's no need to alter the rate of maintenance fluids unless there's a fluid volume concern. Additionally, decreasing the rate would not address the need for a dedicated blood transfusion line if another lumen is available.

B. stop the D51/2NS, check the client's vitals & notify the prescriber: Stopping necessary fluids without cause may compromise fluid balance. Unless there's a compatibility issue or no other lumen, stopping the infusion is not the safest or most efficient action.

C. Fluids cannot be given through a CVC: Central venous catheters are routinely used for administering fluids, medications, and blood products, especially in critical care settings.

D. Insert a 22 gauge peripheral IV to administer the transfusion: While blood can be given through a peripheral IV, using an existing central venous catheter is safer and more efficient, especially when multiple lumens are available. Inserting a new IV unnecessarily increases infection and complication risks.

E. transfuse the unit of packed red blood cells through a separate lumen of the CVC: This is the safest and most appropriate action. Triple-lumen CVCs allow for simultaneous infusions through separate channels without mixing. Blood should be transfused through a dedicated lumen to avoid incompatibility or dilution by other fluids.

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The nurse is assessing a new admission and hears a murmur at the second left intercostal space along the left sternal border. The nurse anticipates the client has a murmur of which valve?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client with heart failure exhibits bibasilar crackles, dyspnea and a respiratory rate of 26/min. The physician prescribes furosemide 40 mg IV and enalapril 5 mg PO. Which parameter would the nurse use to best evaluate if the client is responding to these medications?

Correct Answer is D

Explanation

A client has a triple lumen subclavian central venous catheter (CVC) with D51/2NS infusing through one lumen (port) at 75 mL per hour. The nurse has an order to transfuse one unit of packed red blood cells (PRBCs). The nurse's safest action is to:

Correct Answer is E

Explanation

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