In assessing the apical heart rate of an adult, in what order should the practical nurse (PN) perform the needed tasks?
Expose the left side of the chest.
Locate the point of maximal impulse.
Position the diaphragm of the stethoscope.
Listen for heart sounds.
The Correct Answer is A,B,C,D
A. Exposing the left side of the chest is the first step to access the area where the apical pulse is assessed. This step ensures that the nurse has clear access to the chest for auscultation.
B. Locating the point of maximal impulse (PMI) is the next step once the chest is exposed. The PMI, typically located at the 5th intercostal space at the midclavicular line, is where the heart’s apex is closest to the chest wall.
C. Positioning the diaphragm of the stethoscope on the PMI is the step where the actual auscultation begins. The diaphragm is used to listen for heart sounds.
D. Listening for heart sounds at the PMI is the final step to assess the apical heart rate. This step completes the assessment by allowing the PN to count the heart rate and evaluate the rhythm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The submandibular lymph nodes are located beneath the lower jaw, in the area where the jawbone meets the neck. This is the correct location to palpate for enlargement of these lymph nodes.
B. The temporal bone is located on the side of the head, not relevant to the location of the submandibular lymph nodes. Palpation for these nodes occurs beneath the lower jaw, not near the temporal bone.
C. Lateral to the trachea refers to the location of other lymph nodes such as the anterior cervical or supraclavicular nodes, not the submandibular nodes. Submandibular nodes are specifically beneath the jaw.
D. Above the upper jaw does not correspond to the location of the submandibular lymph nodes. These nodes are palpated beneath the lower jaw, making this option incorrect.
Correct Answer is C
Explanation
A. Stating that the healthcare provider left specific instructions may come across as confrontational and does not address the client's emotional state. The focus should be on empathetic communication rather than emphasizing authority.
B. While acknowledging the client’s feelings is important, this response may not de-escalate the situation. It focuses on the necessity of ambulation rather than addressing the client's anger and offering support.
C. Offering to return in 30 minutes provides the client with a sense of control and acknowledges their feelings. It is a supportive and respectful approach that allows time for the client to calm down and prepares them for ambulation.
D. Explaining that ambulation is necessary to avoid complications can sound directive and may not help in managing the client's anger. It is more effective to acknowledge the client's feelings and offer to help at a later time.
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