A nurse is performing a cardiovascular assessment on a healthy client. In which of the following anatomical landmarks would the nurse expect to palpate the client's Point of Maximal Impulse (PMI)?
Left fourth intercostal space at the sternal border.
Left third intercostal space at the sternal border.
Left second intercostal space at the midclavicular line.
Left fifth intercostal space at the midclavicular line.
The Correct Answer is D
The correct answer is: d. Left fifth intercostal space at the midclavicular line.
Choice A: Left fourth intercostal space at the sternal border
The fourth intercostal space at the sternal border is not the typical location for the Point of Maximal Impulse (PMI). This area is more commonly associated with the tricuspid valve auscultation point. The PMI is usually found more laterally and inferiorly.
Choice B: Left third intercostal space at the sternal border
The third intercostal space at the sternal border is also not the correct location for the PMI. This area is generally used for auscultating the pulmonic valve. The PMI is located further down and towards the midclavicular line.
Choice C: Left second intercostal space at the midclavicular line
The second intercostal space at the midclavicular line is typically where the aortic valve is auscultated. The PMI is not found this high up on the chest.
Choice D: Left fifth intercostal space at the midclavicular line
This is the correct location for palpating the Point of Maximal Impulse (PMI). The PMI is usually located at the apex of the heart, which is found at the left fifth intercostal space along the midclavicular line. This is where the left ventricle is closest to the chest wall and can be felt most strongly during systole.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Helping the client select a low-salt diet is not directly related to addressing tenacious bronchial secretions. While a low-salt diet might have some implications for overall cardiovascular health, it doesn't specifically address the issue of secretions in the lungs.
Choice B rationale:
Encouraging the client to drink 2 to 3 L of water daily is generally beneficial for maintaining hydration and thinning mucus secretions. However, it doesn't directly address the problem of not being able to bring up secretions. Other interventions are more suitable for that issue.
Choice C rationale:
Administering oxygen via nasal cannula at 2 L/min can provide respiratory support, but it doesn't directly address the problem of tenacious bronchial secretions. Oxygen therapy primarily aims to improve oxygenation, not facilitate mucus clearance.
Choice D rationale:
This is the correct choice. Maintaining a semi-Fowler's position (head of the bed elevated to approximately 30-45 degrees) can help improve lung expansion and facilitate drainage of bronchial secretions. This position helps to reduce the pooling of secretions in the airways, making it easier for the client to cough and bring up the mucus.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale:
This choice is not correct because verifying the oxygen flow rate every other day is not part of the discharge teaching for a client on home oxygen therapy. The flow rate should be checked regularly, not just every other day, to ensure the client's safety and well-being.
Choice B rationale:
This choice is correct. Checking the tops of the ears for skin breakdown is important in a client using a nasal cannula for oxygen therapy. Prolonged use of the cannula can lead to irritation and pressure-related skin breakdown behind the ears.
Choice C rationale:
This choice is correct. Posting "no smoking signs in a prominent location in the home" is an important safety measure for a client on oxygen therapy. Oxygen supports combustion, and smoking in the presence of oxygen can lead to fire hazards.
Choice D rationale:
This choice is correct. Checking the cannula position on a regular basis is essential to ensure that the oxygen is being delivered effectively and that the client is not experiencing discomfort or skin breakdown due to improper positioning.
Choice E rationale:
This choice is correct. Applying petroleum ointment to the nares if they become dry and irritated is a suitable intervention to maintain the client's comfort and prevent skin irritation from the cannula.
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