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","C","D"]
Explanation
A. Coordinator: This role involves organizing and integrating the group's activities to achieve the goals effectively. The coordinator helps ensure that tasks are assigned, deadlines are met, and resources are utilized efficiently.
B. Self-confessor: This role involves expressing personal feelings, thoughts, or concerns.
While open communication is important in a team, this role may not always be considered a "necessary task performance role" in the same sense as the others listed. It's more about interpersonal communication rather than task-related functions.
C. Evaluator: This role involves assessing the group's progress toward its goals and providing feedback on performance. The evaluator helps the group identify areas for improvement and make necessary adjustments.
D. Energizer: This role involves motivating and energizing the group members to
maintain their enthusiasm and commitment to the task at hand. The energizer helps boost morale and keeps the group focused on achieving its objectives.
Correct Answer is B
Explanation
A. Reporting the incident to the charge nurse is an important step, but it should come after the immediate action of washing the affected area.
B. Washing the area of the puncture thoroughly with soap and water is the initial step in managing a needlestick injury to minimize the risk of infection.
C. Going to employee health services is important for further assessment and follow-up, but it should be done after washing the area of the puncture.
D. Completing an incident report is an essential part of documenting the needlestick injury, but it is a secondary step that should be taken after the initial action of washing the area.
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