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TOP: NursingProcess: Implementation MSC:NCLEX: Physiological Integrity
COMPLETION
1. A patient is to receive an infusion of 250 mL of platelets over 2 hours through tubing that is
labeled: 1 mL equals 10 drops. How many drops per minute will the nurse infuse?
___________
ANS:
21
To infuse 250 mL over 2 hours, the calculated drip rate is 20.8 drops/min or 21 drops/min.
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Chapter 35: Assessment: Cardiovascular System
Harding: Lewis’s Medical-Surgical Nursing, 12th Edition
MULTIPLE CHOICE
1. An older adult patient who has just arrived in the emergency department has a pulse deficit of
46 beats. Which intervention would the nurse anticipate for this patient?
a. Cardiac catheterization
b. Hourly blood pressure checks
c. Electrocardiographic monitoring
d. Emergent synchronized cardioversion
ANS: C
Pulse deficit is a difference between simultaneously obtained apical and radial pulses. It
indicates that there may be a cardiac dysrhythmia that would best be detected with ECG
monitoring. Frequent BP monitoring, cardiac catheterization, and emergent cardioversion are
used for diagnosis and/or treatment of cardiovascular disorders but would not be as helpful in
determining the immediate reason for the pulse deficit.
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MSC:NCLEX: Physiological Integrity
2. During a physical examination of an older patient, the nurse palpates the point of maximal
impulse (PMI) in the sixth intercostal space lateral to the left midclavicular line. Which action
is the most specific way for the nurse to follow up on this finding?
a. Ask about risk factors for atherosclerosis.
b. Determine family history of heart disease.
c. Assess for symptoms of ventricular hypertrophy.
d. Auscultate carotid arteries for the presence of a bruit.
ANS: C
The PMI should be felt at the intersection of the fifth intercostal space and left midclavicular
line. A PMI found outside these landmarks indicates possible cardiac enlargement, such as
with left ventricular hypertrophy (LVH). The other assessments are part of a general cardiac
assessment but do not represent follow-up for LVH. Cardiac enlargement is not necessarily
associated with atherosclerosis or carotid artery disease.
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3. How would the nurse listen to auscultate for S3 or S4 gallops in the mitral area?
a. Use the diaphragm of the stethoscope with the patient lying flat.
b. Use the bell of the stethoscope with the patient in the left lateral position.
c. Use the diaphragm of the stethoscope with the patient in a supine position.
d. Use the bell of the stethoscope with the patient sitting and leaning forward.
ANS: B
Gallop rhythms generate low-pitched sounds and are most easily heard with the bell of the
stethoscope. Sounds associated with the mitral valve are accentuated by turning the patient to
the left side, which brings the heart closer to the chest wall. The diaphragm of the stethoscope
is best to use for the higher pitched sounds such as S1 and S2.
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4. A patient is being treated for heart failure. Which laboratory test result will the nurse review
to determine the effects of the treatment?
a. Troponin
b. Homocysteine (Hcy)
c. Low-density lipoprotein (LDL)
d. B-type natriuretic peptide (BNP)
ANS: D
Levels of BNP are a marker for heart failure. The other laboratory results would assess for
myocardial infarction (troponin) or the risk for coronary artery disease (Hcy and LDL).
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MSC:NCLEX: Physiological Integrity
5. While doing the hospital admission assessment for a slender older adult, the nurse observes
pulsation of the abdominal aorta in the epigastric area. Which action would the nurse take?
a. Teach the patient about aneurysms.
b. Notify the hospital rapid response team.
c. Instruct the patient to remain on bed rest.
d. Document the finding in the patient record.
ANS: D
Visible pulsation of the abdominal aorta is commonly observed in the epigastric area for thin
individuals. The nurse would simply document the finding in the admission assessment.
Unless there are other abnormal findings (such as a bruit, pain, or hyper/hypotension)
associated with the pulsation, the other actions are not necessary.
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6. A patient is scheduled for a cardiac catheterization with coronary angiography. What
information would the nurse provide before the procedure?
a. It will be important not to move at all during the procedure.
b. A flushed feeling is common when the contrast dye is injected.
c. Monitored anesthesia care will be provided during the procedure.
d. Arterial pressure monitoring will be needed for 24 hours after the test.
ANS: B
A sensation of warmth or flushing is common when the contrast material is injected, which
can be anxiety producing unless it has been discussed with the patient. The patient may
receive a sedative drug before the procedure but monitored anesthesia care is not used.
Arterial pressure monitoring is not routinely used after the procedure to monitor blood
pressure. The patient is not immobile during cardiac catheterization and may be asked to
cough or take deep breaths.
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7. The nurse notes that a patient who was admitted with heart failure has jugular venous
distention (JVD) when lying flat. Which follow-up action would the nurse take?
a. Encourage the patient to drink more liquids.
b. Assess the apical and radial pulse for a pulse deficit.
c. Observe the neck with the patient elevated 45 degrees.
d. Have the patient bear down to perform the Valsalva maneuver.
ANS: C
When the patient is lying flat, the jugular veins are at the level of the right atrium, so JVD is a
common (but not a clinically significant) finding. JVD but is not confirmed based on the data
given. JVD that persists when the patient is sitting at a 30- to 45-degree angle or greater is
significant. JVD is an expected finding when a patient performs the Valsalva maneuver
because right atrial pressure increases. More fluids will further increase any fluid overload.
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8. A patient will be evaluated for rhythm disturbances with a Holter monitor. Which instruction
would the nurse provide?
a. Connect the recorder to a computer once daily.
b. Exercise more than usual while the monitor is in place.
c. Remove the electrodes when taking a shower or tub bath.
d. Keep a diary of daily activities while the monitor is worn.
ANS: D
The patient is taught to keep a diary describing daily activities while Holter monitoring is
being accomplished to help correlate any rhythm disturbances with patient activities. Patients
are taught that they should not take a shower or bath during Holter monitoring and that they
should continue with their usual daily activities. The recorder stores the information about the
patient‘s rhythm until the end of the testing, when it is removed and the data are analyzed.
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9. How would the nurse document a loud humming sound auscultated over the patient‘s
abdominal aorta?
a. Thrill
b. Bruit
c. Murmur
d. Normal finding
ANS: B
A bruit is the sound created by turbulent blood flow in an artery. Auscultating a bruit in an
artery is not normal and indicates pathology. Thrills are palpable vibrations felt when there is
turbulent blood flow through the heart or in a blood vessel. A murmur is the sound caused by
turbulent blood flow through the heart.
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10. A patient who developed chest pain 4 hours ago may be having a myocardial infarction.
Which laboratory test result would be most helpful in indicating myocardial damage?
a. Troponins
b. Myoglobin
c. Homocysteine (Hcy)
d. Creatine kinase-MB (CK-MB)
ANS: A
Cardiac troponins start to elevate 4 to 6 hours after myocardial injury and are highly specific
to myocardium. They are the preferred diagnostic marker for myocardial infarction.
High-sensitivity troponin (hs-cTnT, hs-cTnI) assays provide even earlier detection of a heart
event, within 1-3 hours. Myoglobin rises in response to myocardial injury within 30 to 60
minutes but is nonspecific and rapidly cleared from the body, limiting its use in the diagnosis
of myocardial infarction. Creatine kinase (CK-MB) increases 4 to 6 hours after myocardial
injury but is rarely used now for diagnosis of acute MI. Homocysteine (Hcy) is an amino acid
that is made during protein catabolism. Elevated levels of Hcy are linked to a higher risk of
CVD, peripheral vascular disease, and stroke.
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11. When assessing a newly admitted patient, the nurse notes a murmur along the left sternal
border. To obtain more information about the murmur, which action would the nurse take?
a. Palpate the peripheral pulses.
b. Determine the timing of the sound.
c. Find the point of maximal impulse.
d. Compare apical and radial pulse rates.
ANS: B
Murmurs are caused by turbulent blood flow, such as occurs when blood flows through a
damaged valve. Relevant information includes the position in which the murmur is heard best
(e.g., sitting and leaning forward), the timing of the murmur in relation to the cardiac cycle
(e.g., systole, diastole), and where on the thorax the murmur is heard best. The other
information is important in the cardiac assessment but will not provide information that is
relevant to the murmur.
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12. The nurse hears a murmur between the S1 and S2 heart sounds at the patient‘s left fifth
intercostal space and midclavicular line. How will the nurse record this information?
a. Systolic murmur heard at mitral area
b. Systolic murmur heard at Erb‘s point
c. Diastolic murmur heard at aortic area
d. Diastolic murmur heard at the point of maximal impulse
ANS: A
The S1 signifies the onset of ventricular systole. S2 signifies the onset of diastole. A murmur
occurring between these two sounds is a systolic murmur. The mitral area is the intersection
of the left fifth intercostal space and the midclavicular line. The other responses describe
murmurs heard at different landmarks on the chest and/or during the diastolic phase of the
cardiac cycle.
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13. A registered nurse (RN) is assessing a patient. Which action observed by charge nurse
requires immediate intervention?
a. The nurse presses on the skin over the tibia for 10 seconds to check for edema.
b. The nurse palpates both carotid arteries simultaneously to compare pulse quality.
c. The nurse documents a murmur heard along the right sternal border as a pulmonic
murmur.
d. The nurse places the patient in the left lateral position to check for the point of
maximal impulse.
ANS: B
The carotid pulses should never be palpated at the same time to avoid vagal stimulation,
dysrhythmias, and decreased cerebral blood flow. The charge nurse should intervene to stop
this action immediately. The other assessment techniques also need to be corrected because
they will provide inaccurate data. However, they are not immediately dangerous to the patient.
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14. Which action will the nurse implement for a patient who arrives for a calcium-scoring CT
scan?
a. Insert an IV catheter.
b. Instruct the patient to lie still.
c. Administer oral sedative medications.
d. Confirm that the patient has been fasting.
ANS: B
The patient should remain still during the scan. The procedure is rapid and involves little risk,
so none of the other actions are necessary.
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15. Which information obtained by the nurse who is admitting the patient for magnetic resonance
imaging (MRI) will be important to report to the health care provider before the MRI?
a. The patient has an allergy to shellfish.
b. The patient has a history of atherosclerosis.
c. The patient has a permanent cardiac pacemaker.
d. The patient took the prescribed heart medications today.
ANS: C
MRI is discouraged in those with older model pacemakers and ICDs because the magnets can
change the function of the devices. However, when there is a strong clinical need and the
benefits outweigh the risks, MRI can be done at centers experienced in this procedure. It will
be important to determine the type of pacemaker. Many newer models of pacemakers and
ICDs are approved for use with MRI. The other information does not affect whether the
patient can have an MRI. There is no iodine-based contrast administered for an MRI, so a
shellfish allergy would not affect the plans. A history of atherosclerosis or recent use of heart
medications would not affect the process of the MRI.
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16. The nurse is monitoring a patient who is undergoing exercise (stress) testing on a treadmill.
Which assessment finding requires the most rapid action by the nurse?
a. Patient reports feeling tired
b. Sinus tachycardia at a rate of 110 beats/min
c. Inversion of T waves on the electrocardiogram
d. Blood pressure (BP) increase from 134/68 to 150/80 mm Hg
ANS: C
ECG changes associated with coronary ischemia (such as T-wave inversions and ST segment
depression) indicate that the myocardium is not getting adequate O2 delivery and that the
exercise test should be stopped immediately. Increases in BP and heart rate are normal
responses to aerobic exercise. Feeling tired is also normal as the intensity of exercise increases
during the stress testing.
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17. The standard policy on the cardiac unit states, ―Notify the health care provider for mean
arterial pressure (MAP) less than 70 mm Hg.‖ Which patient‘s status would the nurse report
to the health care provider?
a. Postoperative patient with a BP of 116/42 mm Hg.
b. Newly admitted patient with a BP of 150/87 mm Hg.
c. Patient with left ventricular failure who has a BP of 110/70 mm Hg.
d. Patient with a myocardial infarction who has a BP of 140/86 mm Hg.
ANS: A
The mean arterial pressure (MAP) is calculated using the formula MAP = (systolic BP + 2
diastolic BP)/3. The MAP for the postoperative patient is 67. The MAP in the other three
patients is higher than 70 mm Hg.
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18. The nurse is admitting a patient for a cardiac catheterization and coronary angiogram. Which
information is important for the nurse to communicate to the health care provider before the
test?
a. The patient‘s pedal pulses are +1.
b. The patient is allergic to contrast dye.
c. The patient had a heart attack 1 year ago.
d. The patient has not eaten anything today.
ANS: B
Patients who have allergies to contrast dye will require treatment with medications, such as
corticosteroids and antihistamines before the angiogram. The other information may be
communicated to the health care provider but will not require a change in the usual
pre-cardiac catheterization orders or medications.
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19. A transesophageal echocardiogram (TEE) is planned for a patient hospitalized with possible
endocarditis. Which action included in the standard TEE orders will the nurse need to
accomplish first?
a. Start an IV line.
b. Start O2 per nasal cannula.
c. Place the patient on NPO status.
d. Give lorazepam (Ativan) 1 mg IV.
ANS: C
The patient will need to be NPO for 6 hours preceding the TEE, so the nurse should place the
patient on NPO status as soon as the order is received. The other actions also will need to be
accomplished but not until just before or during the procedure.
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20. The nurse and assistive personnel (AP) on the telemetry unit are caring for four patients.
Which action could the nurse delegate to the AP?
a. Teaching a patient about exercise electrocardiography
b. Attaching ECG monitoring electrodes after a patient bathes
c. Monitoring a patient after a transesophageal echocardiogram
d. Checking the patient‘s catheter site after a coronary angiogram
ANS: B
AP can be educated in standardized lead placement for ECG monitoring. Assessment of
patients who have had procedures where airway maintenance (transesophageal
echocardiography) or bleeding (coronary angiogram) is a concern must be done by the
registered nurse (RN). Patient teaching requires RN level education and scope of practice.
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MSC:NCLEX: Safe and Effective Care Environment
21. The nurse is reviewing the laboratory results for newly admitted patients on the cardiovascular
unit. Which laboratory result is most important to communicate rapidly to the health care
provider?
a. High troponin I level
b. Increased triglyceride level
c. Very low homocysteine level
d. Elevated C-reactive protein level
ANS: A
The elevation in troponin I indicates that the patient has had an acute myocardial infarction.
Further assessment and interventions are indicated. The other laboratory results indicate
increased risk for coronary artery disease but are not associated with acute cardiac problems
that need immediate intervention.
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22. Indicate where the nurse will palpate the posterior tibial artery.
a. 1
b. 2
c. 3
d. 4
ANS: C
The posterior tibial site is located behind the medial malleolus of the tibia.
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23. Which hemodynamic parameter most directly reflects the effectiveness of drugs given to
reduce a patient‘s left ventricular afterload?
a. Cardiac output (CO)
b. Systemic vascular resistance (SVR)
c. Pulmonary vascular resistance (PVR)
d. Pulmonary artery wedge pressure (PAWP)
ANS: B
SVR reflects the resistance to left ventricular ejection, or afterload. Other parameters may be
monitored but do not reflect left-sided afterload as directly.
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MSC:NCLEX: Physiological Integrity
24. After surgery, a patient‘s central venous pressure (CVP) monitor indicates low pressures.
Which action would the nurse take?
a. Administer IV diuretic medications.
b. Increase the IV fluid infusion per protocol.
c. Increase the infusion rate of IV vasodilators.
d. Elevate the head of the patient‘s bed to 45 degrees.
ANS: B
A low CVP indicates decreased preload from hypovolemia and a need for an increase in the
infusion rate. Diuretic administration will contribute to hypovolemia and elevation of the head
or increasing vasodilators may decrease cerebral perfusion.
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MSC:NCLEX: Physiological Integrity
25. Which parameter will the nurse use to evaluate changes in a patient‘s right ventricular
afterload?
a. Central venous pressure (CVP)
b. Systemic vascular resistance (SVR)
c. Pulmonary vascular resistance (PVR)
d. Pulmonary artery wedge pressure (PAWP)
ANS: C
PVR is a measure of right ventricular afterload, which is elevated in conditions such as
pulmonary hypertension The other parameters do not directly assess for right ventricular
afterload.
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MSC:NCLEX: Physiological Integrity
26. A patient requires arterial pressure monitoring. Which action would the nurse plan to take?
a. Balance and calibrate the monitoring equipment every 2 hours.
b. Position the zero-reference stopcock line level with the phlebostatic axis.
c. Disconnect the low pressure alarm to avoid disturbing the patient‘s sleep.
d. Ensure that the patient is supine with the head of the bed flat for all readings.
ANS: B
For accurate measurement of pressures, the zero-reference level would be at the phlebostatic
axis. There is no need to rebalance and recalibrate monitoring equipment every 2 hours.
Accurate hemodynamic readings are possible with the patient‘s head raised to 45 degrees or in
the prone position. Alarms should be activated; if the pressure in the line falls (e.g., when the
line is disconnected), the low-pressure alarm sounds immediately and notifies staff to
promptly correct the problem.
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MSC:NCLEX: Safe and Effective Care Environment
27. Which measurement would be the most sensitive indicator of cardiac function?
a. Central venous pressure (CVP)
b. Systemic vascular resistance (SVR)
c. Pulmonary vascular resistance (PVR)
d. Pulmonary artery wedge pressure (PAWP)
ANS: D
PAWP reflects left ventricular end diastolic pressure (or left ventricular preload) and is a
sensitive indicator of cardiac function. The other values would also provide useful
information, but the most definitive measurement of changes in cardiac function is the PAWP.
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28. Which action would the nurse take first when the low pressure alarm sounds for a patient who
has an arterial line in the left radial artery?
a. Observe for dysrhythmias.
b. Fast flush the arterial line.
c. Check the left hand for pallor.
d. Re-zero the monitoring equipment.
ANS: A
The low pressure alarm indicates a drop in the patient‘s blood pressure, which may be caused
by dysrhythmias or line disconnection. There is no indication to re-zero the equipment. Pallor
of the left hand would be caused by occlusion of the radial artery by the arterial catheter.
Flushing the line would be useful if there is a dampened waveform.
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29. Which action would the nurse take when preparing to assist with the insertion of a pulmonary
artery catheter?
a. Determine if the cardiac troponin level is elevated.
b. Place the patient on NPO status before the procedure.
c. Auscultate heart sounds before and during catheter insertion.
d. Assure that the cardiac monitor is visible during the procedure.
ANS: D
Dysrhythmias can occur as the catheter is floated through the right atrium and ventricle, and it
is important for the nurse to monitor for these during insertion. Pulmonary artery catheter
insertion does not require anesthesia, and the patient will not need to be NPO. Changes in
cardiac troponin or heart and breath sounds are not expected during pulmonary artery catheter
insertion.
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MSC:NCLEX: Physiological Integrity
30. The nurse is assisting with the placement of a pulmonary artery (PA) catheter. What would
the nurse expect to see on the monitor during the procedure as an indication that the catheter
with inflated balloon is placed correctly?
a. PA pressure waveform
b. PA wedge pressure (PAWP) waveform
c. Tracing of the systemic arterial pressure
d. Tracing of the systemic vascular resistance
ANS: B
The purpose of a PA line is to measure PAWP, so the catheter is floated through the
pulmonary artery until the dilated balloon wedges in a distal branch of the pulmonary artery,
and the PAWP readings are available. After insertion, the balloon is deflated, and the PA
waveform will be observed. Systemic arterial pressures are obtained using an arterial line, and
the systemic vascular resistance is a calculated value, not a waveform.
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31. Which finding by the nurse caring for a patient with a right radial arterial line indicates a need
for the nurse to take action?
a. The left hand feels warmer than the right hand.
b. The mean arterial pressure (MAP) is 77 mm Hg.
c. The system is delivering 3 mL of flush solution per hour.
d. The flush bag and tubing were changed 2 days previously.
ANS: A
The cooler temperature of the right hand suggests that blood flow to the right hand may be
impaired; further assessment may lead to plans for removal of the radial catheter to avoid
permanent injury to the right hand. The flush system needs to be changed every 96 hours. A
mean arterial pressure (MAP) of 70-105 mm Hg is normal. Flush systems for hemodynamic
monitoring are set up to deliver 3 to 6 mL/hr of flush solution.
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32. The nurse is caring for a patient who has an arterial catheter in the left radial artery for arterial
pressure–based cardiac output (APCO) monitoring. Which information obtained by the nurse
requires a report to the health care provider?
a. The patient has a positive Allen test result.
b. There is redness at the catheter insertion site.
c. The mean arterial pressure (MAP) is 86 mm Hg.
d. The dicrotic notch is visible in the arterial waveform.
ANS: B
Redness at the catheter insertion site indicates possible infection. The Allen test is performed
before arterial line insertion, and a positive test result indicates normal ulnar artery perfusion.
A MAP of 86 mm Hg is normal, and the dicrotic notch is normally present on the arterial
waveform.
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33. A patient with respiratory failure has arterial pressure–based cardiac output (APCO)
monitoring and is receiving mechanical ventilation with peak end-expiratory pressure (PEEP)
of 12 cm H2O. Which information indicates that a change in the ventilator settings may be
required?
a. The arterial pressure is 90/46.
b. The heart rate is 58 beats/min.
c. The stroke volume is increased.
d. The stroke volume variation is 12%.
ANS: A
The hypotension suggests that the high intrathoracic pressure caused by the PEEP may be
decreasing venous return and (potentially) cardiac output. The other assessment data would
not be a direct result of PEEP and mechanical ventilation.
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34. While listening at the mitral area, the nurse notes abnormal heart sounds at the patient‘s 5th
intercostal space, midclavicular line. After listening to the audio clip, describe how the nurse
will document the assessment finding.
Click here to listen to the audio clip
a. S3 gallop at the mitral area
b. Systolic murmur at mitral area
c. Diastolic murmur at tricuspid area
d. Pericardial friction rub at tricuspid area
ANS: B
The mitral area location is at the intersection of the fifth intercostal space and the
midclavicular line. The murmur is a pansystolic murmur.
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COMPLETION
1. A patient‘s vital signs are pulse 90, respirations 24, and BP 128/64 mm Hg, and cardiac output
is 4.7 L/min. The patient‘s stroke volume is _____ mL. (Round to the nearest whole number.)
ANS:
52