The nurse is assessing a new admission and hears a murmur at the second left intercostal space along the left sternal border. The nurse anticipates the client has a murmur of which valve?
Pulmonic
Aortic
Tricuspid
Mitral
The Correct Answer is A
A. Pulmonic: The pulmonic valve is best auscultated at the second left intercostal space along the left sternal border. A murmur heard in this location is most likely associated with pulmonic valve abnormalities such as pulmonary stenosis or pulmonary regurgitation.
B. Aortic: The aortic valve is auscultated at the second right intercostal space at the right sternal border. A murmur at this site may indicate aortic stenosis or regurgitation, but not when heard on the left side as in this scenario.
C. Tricuspid: Tricuspid valve murmurs are typically heard best at the lower left sternal border, around the fourth or fifth intercostal space. This location is more inferior than where the nurse auscultated the murmur in the current assessment.
D. Mitral: The mitral valve is best heard at the fifth intercostal space at the midclavicular line (the cardiac apex). Murmurs related to mitral stenosis or regurgitation would not typically be heard at the second intercostal space near the sternum.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["200"]
Explanation
Volume ordered is 1 L.
Convert the total volume to milliliters (mL)
1 L = 1000 mL.
Total volume in mL = 1 L × 1000 mL/L = 1000 mL
Total infusion time = 5 hours
Calculate the infusion rate in milliliters per hour (mL/hr).
Infusion rate (mL/hr) = Total volume (mL) / Total infusion time (hours)
= 1000 mL / 5 hours
= 200
The appropriate setting is 200 mL/hr.
Correct Answer is B
Explanation
A. calculate the number of small squares between one QRS complex and the next one and divide by 1500: This method provides an accurate heart rate calculation, but it is more time-consuming and typically used when precision is needed. It is not the quickest method for rapid bedside estimation of rate.
B. use the 3 second markers to count the number of QRS complexes in 6 seconds and multiply by 10: This is the fastest and most commonly used method for quickly estimating heart rate on an ECG strip. By counting the QRS complexes in a 6-second interval and multiplying by 10, the nurse gets an approximate beats-per-minute rate.
C. count the number of large squares in the R-R interval and divide by 300: This method also provides a quick estimate of heart rate but is best suited for regular rhythms. If the rhythm is irregular, this approach can yield inaccurate results.
D. print a 1-minute ECG strip and count the number of QRS complexes: While accurate, this method is inefficient for quick bedside estimation and is rarely used in practice for rapid assessment due to the time it takes to obtain and interpret a full-minute strip.
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