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The nurse is planning to auscultate heart sounds. The history and physical indicates a history of Aortic Valve dysfunction. Where would the nurse auscultate to assess the Aortic Valve?

A.

5th Intercostal Space, Midclavicular Line

B.

2nd Intercostal Space, Left Sternal Border

C.

2nd Intercostal Space, Right Sternal Border

D.

3rd Intercostal Space, Left Sternal Border

Answer and Explanation

The Correct Answer is C

A. 5th Intercostal Space, Midclavicular Line. This is the location for the apical pulse (PMI) at the mitral area, not the aortic valve.

B. 2nd Intercostal Space, Left Sternal Border. This is the location of the pulmonic valve, not the aortic valve.

C. 2nd Intercostal Space, Right Sternal Border. The aortic valve is best auscultated at the right second intercostal space, next to the sternum.

D. 3rd Intercostal Space, Left Sternal Border. This is the Erb’s point, which provides equal S1 and S2 sounds, but it is not the best location for auscultating aortic valve dysfunction.


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Related Questions

Correct Answer is C

Explanation

A. 5th Intercostal Space, Midclavicular Line. This is the location for the apical pulse (PMI) at the mitral area, not the aortic valve.

B. 2nd Intercostal Space, Left Sternal Border. This is the location of the pulmonic valve, not the aortic valve.

C. 2nd Intercostal Space, Right Sternal Border. The aortic valve is best auscultated at the right second intercostal space, next to the sternum.

D. 3rd Intercostal Space, Left Sternal Border. This is the Erb’s point, which provides equal S1 and S2 sounds, but it is not the best location for auscultating aortic valve dysfunction.

Correct Answer is A

Explanation

A. Paralytic ileus. A postoperative complication in which the intestines stop moving due to anesthesia or surgical trauma. Absence of bowel sounds, abdominal distention, and no flatus are key signs.

B. Incisional infection. An incisional infection would present with redness, warmth, drainage, and fever, but not absence of bowel sounds.

C. Fecal impaction. Fecal impaction causes stool retention, and the client might still pass small amounts of liquid stool, whereas paralytic ileus presents with no bowel movement at all.

D. Health care-associated Clostridium difficile. C. difficile infection presents with frequent watery diarrhea, not absent bowel sounds.

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