A nurse is caring for a client with a heart murmur due to mitral valve disease. Where would the nurse hear the murmur the loudest?
Fourth intercostal space, right sternal border
Second intercostal space, right sternal border
Fifth intercostal space, left midclavicular line
Third intercostal space, left midclavicular line .
The Correct Answer is C
A heart murmur due to mitral valve disease is typically heard loudest over the mitral area, which is located at the fifth intercostal space in the left midclavicular line.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While repositioning the limb and reassessing might be a part of the overall evaluation, it should not be the immediate action. The symptoms described are indicative of a serious issue that requires immediate medical attention.
Choice B rationale
Applying a warm blanket will not address the underlying issue. The symptoms described suggest a problem with circulation that needs immediate medical attention.
Choice C rationale
Notifying the healthcare provider is the correct immediate action. The symptoms described suggest that the patient may be experiencing a complication such as occlusion of the stent. This is a medical emergency that requires immediate intervention.
Choice D rationale
Elevating the extremity on a pillow is not the immediate action to take. While elevation can help with conditions like edema, it does not address the serious symptoms the patient is experiencing.
Correct Answer is B
Explanation
Choice A rationale
Fewer doses of insulin may not necessarily be required with frequent self-monitoring of blood glucose. The need for insulin is determined by blood glucose levels, not the frequency of monitoring.
Choice B rationale
Frequent self-monitoring of blood glucose assists in gaining control over glucose levels. It can immediately tell you the effects of food choices, physical activity, and medication on blood glucose control.
Choice C rationale
While good blood glucose control can help minimize other health problems, frequent self- monitoring of blood glucose does not directly minimize other health problems.
Choice D rationale
Frequent self-monitoring of blood glucose is not necessarily the most cost-efficient method for glucose control. The cost efficiency depends on various factors, including the cost of testing supplies and the frequency of testing.
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