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. Urinary frequency. Urinary frequency is an increased urge to void, which can be caused by a UTI but does not explain cloudy, foul-smelling urine on its own.

B. Urinary tract infection (UTI). Cloudy, dark amber urine with a foul odor is indicative of a UTI due to bacterial presence, pus (pyuria), and possibly hematuria.

C. Urinary retention. Urinary retention leads to distended bladder, incomplete emptying, and overflow incontinence, but it does not cause foul-smelling, cloudy urine unless it leads to secondary infection.

D. Urinary incontinence. Incontinence is the involuntary loss of urine, but it does not cause cloudy or foul-smelling urine unless there is an underlying infection.

A. Press the skin over the client's ankle bone. B. Observe for non blanching, pinpoint-size, red or purple spots on the skin of the abdomen. C. Lightly palpate the skin using the fingertips. D. Grasp a fold of skin on the client's forearm or near the sternum.

Correct Answer is D

Explanation

A. Press the skin over the client's ankle bone. Skin over the bony prominences is not ideal for assessing turgor, as it may not accurately reflect dehydration.

B. Observe for non-blanching, pinpoint-size, red or purple spots on the skin of the abdomen. This describes petechiae, which is a sign of bleeding disorders, not hydration status.

C. Lightly palpate the skin using the fingertips. Palpation does not assess elasticity.

D. Grasp a fold of skin on the client's forearm or near the sternum. The best way to check for dehydration is by pinching the skin on the sternum or forearm and observing how quickly it returns to normal.

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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

Naxlex Comprehensive Predictor Exams

A nurse is emptying a client's urinal when she notices the urine is dark amber, cloudy, and has a foul or unpleasant odor. The nurse should identify that these findings are likely to be the result of which of the following?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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