A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the client's apical pulse. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
right upper sternal border
left upper sternal border
left lower sternal border
5th intercostal space, midclavicular line
The Correct Answer is {"xRanges":[234.765625,254.765625],"yRanges":[107.609375,127.609375]}
A. The right upper sternal border is not the correct placement for auscultating the apical pulse. This location is more appropriate for assessing heart sounds related to the aortic valve.
B. The left upper sternal border is not the correct placement for auscultating the apical pulse.
This location is more appropriate for assessing heart sounds related to the pulmonic valve.
C. The left lower sternal border is not the correct placement for auscultating the apical pulse.
This location is more appropriate for assessing heart sounds related to the tricuspid valve.
D. 5th intercostal space, midclavicular line is the correct placement for auscultating the apical pulse. This location corresponds to the apex of the heart, which is where the apical pulse (also known as the point of maximum impulse or PMI) can be best heard.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A. Keeping the client's bed in the lowest position helps minimize the potential fall distance if the client attempts to get out of bed.
B. Assessing the client every 4 hours is a good practice for general monitoring but may not be specific to fall prevention. More frequent assessments may be necessary for a client at high risk for falls.
C. Keeping the client's room dark at night can actually increase the risk of falls. It's important to ensure there is adequate lighting to help the client navigate safely.
D. Teaching the client to use the call light allows them to request assistance when needed, reducing the likelihood of attempting to move or get out of bed independently.
E. Placing a fall-risk identification band on the client's wrist helps alert all healthcare providers that the client is at risk for falls. This information is crucial for ensuring appropriate precautions are taken.
Correct Answer is A
Explanation
A. Gloves should be removed first. This is because the gloves are the items most likely to be contaminated. To remove gloves, grasp the outside edge near the wrist and peel them off, turning them inside out as you go.
B. The gown should be removed next. The gown protects the nurse's clothing from contamination. Untie or unfasten the gown, and then carefully remove it, taking care to avoid touching the outside of the gown.
C. Face shields or goggles should be removed next if used. This helps protect the eyes and face. Handle the shield or goggles by the headband or earpieces and remove them without touching the front.
D. Mask should be removed last. The mask helps protect the respiratory system. Untie or unhook the mask from behind the ears or head and discard it.
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