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 D
Explanation
A. Missing the child every day is a normal part of the grieving process but does not indicate improvement in managing depression.
B. Drinking 4 to 6 bottles of beer each evening suggests the client may be using alcohol as a coping mechanism, indicating poor management of depression.
C. Expressing that drunk driving is inexcusable shows the client has a strong opinion on the matter, but it does not necessarily indicate improvement in the client’s emotional health.
D. Sleeping through the night often indicates an improvement in the client’s ability to rest and manage depressive symptoms, suggesting a positive response to treatment.
Correct Answer is A
Explanation
A. This activity addresses both physical and social needs. It provides a gentle physical activity that can be enjoyed by people with limited mobility. It also encourages social interaction and teamwork, promoting a sense of belonging and camaraderie.
B. An open-air concert is enjoyable but may not fully engage residents in both physical and social aspects. While it offers entertainment, it lacks interactive elements that foster social engagement and physical involvement.
C. This activity requires more mobility than wheelchair-bound residents may have, especially if it involves walking on uneven terrain or sitting on the ground.
D. A tea party in the courtyard is a social activity but does not offer as much physical engagement or variety as a picnic in the park. While it is a pleasant option, it may not provide the same level of physical stimulation and change of scenery.
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