The nurse is caring for a patient with mitral valve disease. At which anatomic landmark will the nurse hear a heart murmur the loudest?

Fifth intercostal space, left midclavicular line

Fourth intercostal space, right sternal boarder

Third intercostal space, left midclavicular line

Second intercostal space, right sternal boarder

Answer and Explanation

The Correct Answer is A

A. The fifth intercostal space at the left midclavicular line is the location of the mitral valve, where murmurs associated with mitral valve disease are best auscultated.

B. The fourth intercostal space at the right sternal border is the location for assessing the tricuspid valve, not the mitral valve.

C. The third intercostal space at the left midclavicular line is not associated with loudest auscultation of the mitral valve murmur.

D. The second intercostal space at the right sternal border is where the aortic valve sounds are best heard.

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Correct Answer is C

Explanation

A. While drug dependence can be a concern with long-term use, it is not the immediate priority in an emergency setting where the goal is to stabilize the patient in status epilepticus.

B. Cardiac rhythm monitoring is important when administering certain medications, but lorazepam primarily affects the central nervous system and respiratory system, making oxygen saturation monitoring more critical.

C. Pulse oximetry is the priority assessment as IV lorazepam can depress the respiratory system, leading to hypoxia. Monitoring oxygen saturation helps ensure the patient maintains adequate respiratory function during administration.

D. Assessing pain is important in patient care, but it is not the priority in managing a patient in status epilepticus, where stabilization is essential.

A. "Using three drugs at the same time enhances suppression of viral replication." B. "If the virus becomes resistant to this combination, I will be switched to another combination of medications." C. "Because the combination of medications kills the virus, I can stop taking the medications." D. "My CD4 count should increase with this medication regimen."

Correct Answer is C

Explanation

A. This is a correct statement, as using multiple drugs helps to reduce the likelihood of resistance and enhances viral suppression.

B. This is accurate; if resistance develops, alternative medications or combinations can be considered.

C. This statement indicates a misunderstanding. Antiretroviral medications do not kill the virus; they suppress its replication. Lifelong adherence to antiretroviral therapy is necessary to manage HIV and prevent viral rebound.

D. Correct, as an effective regimen should lead to an increase in CD4 count and improved immune function.

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The nurse is caring for a patient with mitral valve disease. At which anatomic landmark will the nurse hear a heart murmur the loudest?

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Naxlex Comprehensive Predictor Exams

The healthcare provider has prescribed intravenous (IV) lorazepam for the patient in status epilepticus. During administration, which is the priority assessment by the nurse?

Correct Answer is C

Explanation

Which statement made by a patient who is diagnosed with human immunodeficiency virus (HIV) and is prescribed three antiretroviral medications, indicates the need for further teaching about the medication combination?

Correct Answer is C

Explanation

The nurse teaching a patient who is diagnosed with human immunodeficiency virus (HIV), would include which information regarding an activity that has the highest potential to spread the disease to relatives or friends in a household?

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