A nurse is collecting data from a client who has mitral valve regurgitation. In which of the following areas should the nurse place the stethoscope to auscultate a murmur? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
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The Correct Answer is {"xRanges":[124.765625,154.765625],"yRanges":[96.609375,126.609375]}
{"A":{"choice":"-","reason":"
is not the correct answer because the tricuspid area is not the location where a nurse should auscultate for a murmur related to mitral valve regurgitation. The tricuspid area is located at the fifth intercostal space at the lower left sternal border, and is the site where blood flows from the right atrium to the right ventricle during systole.<\/p>"},"B":{"choice":"-","reason":"
The correct answer is choice B, the mitral area. When auscultating for a murmur in a client with mitral valve regurgitation, the nurse should place the stethoscope at the mitral area, which is the fifth intercostal space at the left midclavicular line. This is because the mitral valve is located at this spot and is the site where blood flows from the left atrium to the left ventricle during systole.<\/p>"},"C":{"choice":"-","reason":"
is not the correct answer because the aortic area is not the location where a nurse should auscultate for a murmur related to mitral valve regurgitation. The aortic area is found at the second intercostal space at the right sternal border, and is the site where blood flows from the left ventricle to the aorta during systole.
\r\nChoiceD4 is not the correct answer because the pulmonic area is not the location where a nurse should auscultate for a murmur related to mitral valve regurgitation. The pulmonic area is located at the second intercostal space at the
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\r\nleft sternal border, and is the site where blood flows from the right ventricle to the pulmonary artery during systole.<\/p>"},"D":{"choice":"-","reason":"
The correct answer is choice B, the mitral area. When auscultating for a murmur in a client with mitral valve regurgitation, the nurse should place the stethoscope at the mitral area, which is the fifth intercostal space at the left midclavicular line. This is because the mitral valve is located at this spot and is the site where blood flows from the left atrium to the left ventricle during systole.<\/p>"}}
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
The correct answer is Choice A, Choice D.
Choice A rationale: Tachycardia, or an increased heart rate, is a common symptom of dehydration in infants. The body attempts to maintain adequate blood circulation despite reduced fluid volume by increasing the heart rate, which is a compensatory mechanism.
Choice B rationale: Bloating is not typically associated with dehydration in infants. Dehydration usually results in symptoms like dry mucous membranes and decreased skin turgor, rather than gastrointestinal symptoms like bloating.
Choice C rationale: Hypertension, or high blood pressure, is uncommon in dehydrated infants. Dehydration generally leads to hypotension (low blood pressure) due to decreased fluid volume in the circulatory system, which can result in reduced blood pressure.
Choice D rationale: Irritability is a frequent symptom of dehydration in infants. Reduced fluid intake and electrolyte imbalances can cause discomfort and distress, leading to irritability and increased fussiness in dehydrated infants.
Correct Answer is D
Explanation
Answer is: d. Reposition the client.
Explanation: Repositioning the client can help alleviate pain by redistributing pressure and promoting comfort. Since the client's pain level is relatively low (2 on a scale of 0 to 10), this non-pharmacological intervention is an appropriate initial action.
Choice a. is wrong because maintaining the client on bed rest is not an appropriate action for a pain level of 2. Instead, the nurse should encourage the client to mobilize and perform appropriate exercises to prevent complications related to immobility.
Choice b. is wrong because applying a warm, moist compress to the incision area might not be the best action for a client who is 24 hours postoperative, as it could increase the risk of infection and cause discomfort. Cold compresses are often used in the initial postoperative period to reduce swelling and promote comfort.
Choice c. is wrong because administering an additional dose of pain medication is not necessary at this point, as the client's pain level is relatively low. The nurse should consider non-pharmacological interventions first and reassess the client's pain level to determine the need for further pain relief.
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