A nurse is collecting data from a client during a routine physical exam. Which of the following locations should the nurse identify as the point of maximum impulse?

Answer and Explanation

The Correct Answer is A

Choice A: The fifth intercostal space at the midclavicular line
The point of maximal impulse (PMI), also known as the apical impulse, is usually located in the fifth intercostal space at the midclavicular line. This is the point on the precordium farthest outwards (laterally) and downwards (inferiorly) from the sternum at which the cardiac impulse can be felt.

Choice B: The first intercostal space at the sternal border
The first intercostal space at the sternal border is not typically the location of the PMI. The PMI is usually located in the fifth intercostal space at the midclavicular line.

Choice C: The second intercostal space at the sternal border
The second intercostal space at the sternal border is not typically the location of the PMI. The PMI is usually located in the fifth intercostal space at the midclavicular line.

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Correct Answer is D

Explanation

Choice A reason:Aspiration pneumonia is typically caused by inhalation of foreign material into the lungs rather than by contagious pathogens. Therefore, standard precautions are usually sufficient unless a secondary infection with a transmissible organism is present.

Choice B reason: Applying petroleum jelly to the client's nares may provide comfort but is not a priority in the care plan.

Choice C reason: Maintaining the client in a supine position is contraindicated as it can increase the risk of aspiration.

Choice D reason: Clients with hypoxia may experience symptoms such as confusion, restlessness, and dizziness, which can increase the risk of falls. Implementing fall precautions is a proactive measure to ensure patient safety in this context.

A. A client who has a spinal cord injury and has a prescription for a condom catheter. B. A client who has immune thrombocytopenic purpura and a platelet count of 150,000/mm. C. A client who reports pain in his left calf and has a respiratory rate of 32/min. D. A client who requires a signed consent form prior to cardiac catheterization.

Correct Answer is C

Explanation

Choice A reason: While the client with a spinal cord injury does need care, it is not as immediately life-threatening as the symptoms described in choice C.

Choice B reason: A platelet count of 150,000/mm is within the normal range (150,000 to 450,000/mm), so this client's situation is not urgent.

Choice C reason: The client reporting pain in the left calf with an elevated respiratory rate could be experiencing a deep vein thrombosis (DVT) leading to a pulmonary embolism, which is a medical emergency.

Choice D reason: Obtaining a signed consent form is important but not as time sensitive as assessing and treating a potential DVT.

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A nurse is collecting data from a client during a routine physical exam. Which of the following locations should the nurse identify as the point of maximum impulse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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