A nurse can most accurately assess a client's apical heart rate by which of the following methods?
Listen with a stethoscope at the second intercostal space left sternum
Listen with the stethoscope at the fifth intercostal space at the sternum
C. Listen with the stethoscope at the fifth intercostal space left mid clavicular line
Listen with a stethoscope at the neck to the right of the coracoid process.
The Correct Answer is C
The correct answer is choice C: Listen with the stethoscope at the fifth intercostal space left mid clavicular line. This is the correct location to auscultate the apical pulse or apical heart rate. The apical pulse is the sound of the heart beating heard through a stethoscope placed over the apex of the heart, which is located at the fifth intercostal space at the left mid-clavicular line. The second intercostal space at the left sternum is the location to auscultate the aortic valve, while the fifth intercostal space at the sternum is the location to auscultate the tricuspid valve. The neck to the right of the coracoid process is not a location to auscultate the apical pulse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. By asking for a sitter to stay at the bedside to keep the client company and minimize the risk for falls, the nurse is demonstrating the ethical principle of nonmaleficence. Nonmaleficence refers to the duty to do no harm to the client, and in this case, the nurse is taking proactive steps to prevent harm to the client by ensuring their safety and well-being. Veracity (choice B) refers to the principle of truthfulness and honesty in communication, fidelity (choice C) refers to the principle of keeping promises and maintaining trust in the nurse-client relationship, and beneficence (choice D) refers to the principle of promoting good and doing what is in the best interest of the client. While all of these principles are important in nursing practice, the nurse in this scenario is primarily demonstrating nonmaleficence by taking action to prevent harm to the client.
Correct Answer is ["B","C","D","E"]
Explanation
correct answers are:
B Use standard terminology and commonly used medical abbreviations.
C Factually record the date and time the healthcare provider was notified of a concern and exact healthcare provider response.
D o not document nursing interventions ahead of time before performing them.
E Document nursing interventions performed by the nurse who is documenting.
Nurses play a crucial role in patient care and documentation guidelines are important to ensure accuracy, completeness, and continuity of care. Using standard terminology and commonly used medical abbreviations is important to ensure that documentation is clear, concise, and easily understood by all members of the healthcare team. This practice helps avoid confusion, facilitates communication, and ensures that all healthcare professionals can accurately interpret and act upon the documented information.
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