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. Troponin is a marker for cardiac muscle damage. It is not directly related to anorexia and malnutrition.
B. Creatine kinase is also a marker for muscle damage, particularly in conditions like heart attacks or muscular disorders. It is not directly related to anorexia and malnutrition.
C. Total bilirubin is related to liver function. While severe malnutrition can affect liver function, it's not the primary marker for malnutrition.
D. Albumin is a protein synthesized by the liver and is an important indicator of nutritional status. In cases of malnutrition, especially protein-calorie malnutrition, serum albumin levels tend to decrease. This is due to the body's decreased ability to synthesize proteins when there is a lack of adequate nutrition.

A. Dilute each medication with 10 mL of tap water. B. Pinch the tube prior to attaching the medication syringe. C. Reattach the suction directly after administering the medication. D. Mix the three medications together prior to administering.

Correct Answer is B

Explanation

A. Diluting each medication with tap water is not a recommended practice. It's important to administer medications in their prescribed form to ensure the client receives the correct dose.
B. Pinching the tube prior to attaching the medication syringe helps prevent the medication from being immediately pulled into the suction equipment. This allows the medication to stay in the stomach for absorption.
C. Reattaching the suction directly after administering the medication would
immediately start suctioning again, which could pull the medication out of the stomach before it has a chance to be absorbed.
D. Mixing the three medications together is not recommended, as some medications may interact with each other, potentially leading to undesirable effects. Each medication should be administered separately to ensure proper absorption and effectiveness.

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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

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