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 B
Explanation
Choice A rationale:
Enclosing the dressing in a single clear plastic bag and discarding it in the bedside trash receptacle is not the appropriate method for disposing of a dressing saturated with blood and purulent drainage. Blood and purulent drainage are considered potentially infectious materials, and they should be handled as biohazardous waste to prevent the spread of infection.
Choice B rationale:
This is the correct choice. When dealing with potentially infectious materials such as blood and purulent drainage, it's essential to dispose of them in a biohazardous waste container. This specialized container is designed to contain potentially infectious materials and prevent their spread, thereby protecting both healthcare workers and the environment.
Choice C rationale:
Discarding the dressing in the bedside trash receptacle is not the recommended approach for disposing of materials that are contaminated with blood and purulent drainage. Simply discarding it in the regular trash increases the risk of infection transmission and is not compliant with proper infection control practices.
Choice D rationale:
Double-bagging the dressing in clear bags and labeling it "biohazard" is a good practice to ensure proper containment. However, it's not the most comprehensive method of disposal. Placing the dressing in a dedicated biohazardous waste container is a more secure and standardized method for disposing of potentially infectious materials.
Correct Answer is A
Explanation
Choice A rationale:
This situation represents an example of assault. Assault is the threat of bodily harm or unwanted physical contact, which creates an apprehension of fear in the victim. In this case, the laboratory technician's actions of restraining the client's arm against their will for blood drawing without consent is a form of assault as it involves an intentional act causing fear of harm.
Choice B rationale:
While telling a client that the nurse "does not know anything" is unprofessional and disrespectful, it doesn't constitute assault. This scenario is more related to issues of communication and respect rather than a direct threat of physical harm.
Choice C rationale:
Restraining a client at bedtime to prevent wandering is not assault. This scenario might involve ethical considerations and the appropriate use of restraints, but it doesn't meet the legal definition of assault, which involves a threat of physical harm.
Choice D rationale:
Threatening to tie down a client if they try to get up from the chair is an example of assault. This action creates an apprehension of fear in the client by implying a physically harmful act. It's a direct threat that falls under the category of assault.
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