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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While lung injury could occur in traumatic situations, it is not the primary reason for mechanical ventilation in the context of a spinal cord injury.
B. A history of smoking may affect lung health but does not directly justify the immediate need for mechanical ventilation following a spinal cord injury.
C. The nerves that control lung function may be injured in a cervical spinal cord injury, particularly at higher levels like C3-C5, leading to respiratory muscle paralysis and necessitating mechanical ventilation to support breathing.
D. While unconsciousness may complicate breathing, the primary concern is the loss of function in the spinal cord nerves controlling respiration.
Correct Answer is D
Explanation
A. Using a draw sheet may cause twisting, which can compromise spinal alignment.
B. Asking the patient to assist may risk further spinal injury.
C. Turning hips and shoulders separately risks disrupting spinal alignment, making this an unsafe approach.
D. Log rolling is the safest way to turn a patient with a spinal cord injury, maintaining spinal alignment and preventing further injury. It requires one person to stabilize the head while others turn the body as a single unit.
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