A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers?
The left fifth intercostal space at the midclavicular line.
The left fifth intercostal space.
The left second intercostal space.
The right second intercostal space.
The Correct Answer is C
A. The left fifth intercostal space at the midclavicular line is the location for palpating the apical pulse, not the pulmonic area. This area is used to assess the heart's apex, particularly for detecting the point of maximal impulse (PMI).
B. The left fifth intercostal space is also associated with the apical pulse, but it lacks the specificity of the midclavicular line, making it less precise for identifying the pulmonic area.
C. The left second intercostal space is the correct location for palpating the pulmonic area. This area is where the pulmonic valve is best auscultated and palpated, allowing for the detection of any abnormal pulsations or sounds related to the pulmonary artery.
D. The right second intercostal space is the location for palpating the aortic area, not the pulmonic area. This site is used to assess the aortic valve and any related abnormalities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Autonomy:This principle refers to respecting a patient's right to make their own decisions about their healthcare. In this scenario, the nurse's actions did not directly impact the client's autonomy, as the client was not involved in the decision-making process regarding the incident report.
B. Veracity:This principle involves being truthful and transparent. By not completing an incident report, the nurse failed to uphold veracity, as this action concealed the truth about the medication error, potentially affecting future care and trust in the healthcare system.
C. Confidentiality:This principle is about protecting patient information. The nurse's failure to report the incident did not violate confidentiality, as it did not involve disclosing or mishandling the client's private information.
D. Beneficence:This principle focuses on doing good and acting in the best interest of the patient. While the nurse's intention might have been to avoid unnecessary alarm, failing to report the incident could prevent the healthcare team from learning from the mistake and improving patient safety, thus indirectly affecting beneficence.
Correct Answer is D
Explanation
Choice A rationale:
Helping the client select a low-salt diet is not directly related to addressing tenacious bronchial secretions. While a low-salt diet might have some implications for overall cardiovascular health, it doesn't specifically address the issue of secretions in the lungs.
Choice B rationale:
Encouraging the client to drink 2 to 3 L of water daily is generally beneficial for maintaining hydration and thinning mucus secretions. However, it doesn't directly address the problem of not being able to bring up secretions. Other interventions are more suitable for that issue.
Choice C rationale:
Administering oxygen via nasal cannula at 2 L/min can provide respiratory support, but it doesn't directly address the problem of tenacious bronchial secretions. Oxygen therapy primarily aims to improve oxygenation, not facilitate mucus clearance.
Choice D rationale:
This is the correct choice. Maintaining a semi-Fowler's position (head of the bed elevated to approximately 30-45 degrees) can help improve lung expansion and facilitate drainage of bronchial secretions. This position helps to reduce the pooling of secretions in the airways, making it easier for the client to cough and bring up the mucus.
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