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?
5th Intercostal Space, Midclavicular Line
2nd Intercostal Space, Left Sternal Border
2nd Intercostal Space, Right Sternal Border
3rd Intercostal Space, Left Sternal Border
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Nausea – Not a primary manifestation of hypoxia. Hypoxia primarily affects oxygen delivery to tissues, leading to respiratory and neurological changes.
B. Dysphagia – Difficulty swallowing is not a common sign of hypoxia. It is more often associated with neurological conditions or structural abnormalities.
C. Warm, dry skin – Hypoxia typically causes cool, clammy skin due to vasoconstriction and poor oxygenation, not warm, dry skin.
D. Cyanosis – Correct. Cyanosis (bluish discoloration of the skin, lips, or nail beds) occurs due to inadequate oxygenation of the blood, making it a key sign of hypoxia.
Correct Answer is ["A","D","E"]
Explanation
A. Relief of urinary retention. Urinary catheterization is indicated for clients who cannot void effectively, which can lead to bladder distension and complications.
B. Convenience for the nursing staff or the client's family. Catheterization should never be done for staff convenience due to the high risk of infection (CAUTI - catheter-associated urinary tract infection).
C. Routine acquisition of a urine specimen. Routine urine specimens should be obtained through clean-catch or midstream methods, unless a sterile sample is required for culture and sensitivity testing.
D. Measurement of residual urine after urination. Catheterization may be needed to measure post-void residual volume in cases of urinary retention.
E. Presence of an open perineal wound. A catheter can help prevent urine contamination of an open wound in the perineal area, reducing the risk of infection.
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