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 C
Explanation
A. Rubbing hands and arms to dry is not the correct action for hand hygiene. After applying soap, hands should be rinsed thoroughly with water and then dried using a clean towel or air dryer.
B. Adjusting the water temperature to feel hot is not recommended for hand hygiene.
Water that is too hot can be uncomfortable and may even cause skin irritation. The water should be comfortably warm.
C. Applying 4 to 5 mL of liquid soap to the hands is the correct action. This provides an adequate amount of soap to create a good lather for effective handwashing.
D. Holding the hands higher than the elbows is not a necessary step for hand hygiene.
The focus should be on thoroughly cleaning the hands, not on the position of the hands in relation to the elbows.
Correct Answer is A
Explanation
A. During the Assessment phase, the nurse gathers information about the client's health status, including any potential allergies. This information is crucial for planning safe and effective care.
B. The Planning phase involves developing a care plan based on the assessment data.
While allergies are an important consideration in planning care, they are first identified during the assessment phase.
C. The Implementation phase involves carrying out the care plan. While it is important to be aware of allergies during this phase to ensure the safe administration of treatments, the initial identification of allergies occurs in the assessment phase.
D. The Evaluation phase involves assessing the client's response to interventions and determining if goals have been met. While allergies are relevant in evaluating the client's response to certain treatments, they are initially identified during the assessment phase.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today