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

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. A chest tube to water seal is used to remove air or fluid from the pleural space. This does not directly impact the client's potassium levels.

B. A tracheostomy tube attached to humidified oxygen delivers oxygen directly to the client's airway and does not have a direct effect on potassium levels.

C. An indwelling urinary catheter to gravity drainage does not typically cause significant potassium loss. Urinary catheters primarily collect urine, which contains waste products, rather than electrolytes like potassium.

D. A client with an NG tube to suction may experience loss of gastric contents, which can lead to the loss of electrolytes, including potassium. This places the client at risk for hypokalemia.

A. Increased fiber in the diet B. Ignoring the urge to defecate C. Inadequate fluid intake D. Increased activity E. Excessive laxative use

Correct Answer is ["B","C","E"]

Explanation

A. Increased fiber in the diet is not a cause of constipation, but rather a preventive measure that can help promote regular bowel movements by adding bulk and softness to the stool.
B. Ignoring the urge to defecate is a cause of constipation, as it can lead to hardening and accumulation of fecal matter in the colon, resulting in difficulty and pain during defecation.
C. Inadequate fluid intake is a cause of constipation, as it can contribute to dehydration and reduced stool moisture, making it harder and drier to pass.
D. Increased activity is not a cause of constipation, but rather a beneficial factor that can stimulate intestinal motility and facilitate bowel elimination.
E. Excessive laxative use is a cause of constipation, as it can interfere with the normal functioning of the colon and cause dependence, leading to decreased bowel tone and reduced peristalsis.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for four clients who have drainage tubes. Which of the following clients should the nurse recognize as being at risk for hypokalemia?

Correct Answer is D

Explanation

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)

Correct Answer is ["B","C","E"]

Explanation

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