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

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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Correct Answer is B

Explanation

A. Move body parts rapidly through the movements. Passive range of motion (ROM) should be performed slowly and gently to prevent injury or pain.

B. Support extremities above and below joints. Supporting both above and below the joint helps prevent excessive strain and allows for controlled movement.

C. Continue moving body parts if muscle spasticity occurs. If muscle spasticity occurs, the nurse should stop and reassess before continuing, to avoid injuring the client.

D. Stretch the body part just beyond the existing range of motion. The nurse should never push beyond the client’s normal range, as this can cause pain or injury.

A. Dysuria B. Oliguria C. Nocturia D. Urgency

Correct Answer is B

Explanation

A. Dysuria. Dysuria refers to painful or difficult urination, not low urine output.

B. Oliguria. Oliguria is defined as urine output less than 400 mL in 24 hours, which fits this case (250 mL in 24 hours).

C. Nocturia. Nocturia is frequent urination at night, not low urine output.

D. Urgency. Urgency refers to a sudden, strong need to urinate, not decreased urine production.

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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?

Nursing Test Bank

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