In the context of interprofessional care of the client and family, where should a nurse position the stethoscope on the chest to assess a client’s apical heart rate?

On the left side at the midclavicular line, fifth intercostal space.

Directly over the heart on the sternum.

On the right side at the midclavicular line, fourth intercostal space.

At the midaxillary level on the left side.

Answer and Explanation

The Correct Answer is A

Choice A rationale
The apical pulse, also known as the point of maximal impulse (PMI), is located at the fifth intercostal space at the left midclavicular line. This is the location where the heartbeat is strongest and is the standard location for assessing the apical heart rate.
Choice B rationale
Placing the stethoscope directly over the heart on the sternum is not the standard method for assessing the apical heart rate. While the sternum is close to the heart, it is not the location where the heartbeat is strongest or most easily heard.
Choice C rationale
The right side at the midclavicular line, fourth intercostal space, is not the standard location for assessing the apical heart rate. The heart is located more towards the left side of the chest, and the apical pulse is typically not as easily heard on the right side.
Choice D rationale
The midaxillary line on the left side is not the standard location for assessing the apical heart rate. While this location is on the left side of the chest, it is not where the heartbeat is strongest or most easily heard.

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Correct Answer is C

Explanation

Choice A rationale
Administering Ibuprofen as scheduled is a proper nursing intervention for a patient with pericarditis. Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can help reduce inflammation and relieve pain.
Choice B rationale
Monitoring the patient for complications of cardiac tamponade is a proper nursing intervention for a patient with pericarditis. Cardiac tamponade is a serious condition that can occur as a complication of pericarditis.
Choice C rationale
Placing the patient in a supine position to relieve pain is not a proper nursing intervention for a patient with pericarditis. This position could actually increase the patient’s discomfort.
Instead, the patient should be positioned upright and leaning forward to help relieve pain.
Choice D rationale
Monitoring the patient for pulsus paradoxus and muffled heart sounds is a proper nursing intervention for a patient with pericarditis. These are potential signs of worsening pericarditis or complications such as cardiac tamponade.

A. Heberden’s nodes. B. Bouchard’s nodes. C. Janeway lesions. D. Tophi.

Correct Answer is C

Explanation

Choice A rationale
Heberden’s nodes are bony swellings that occur at the distal interphalangeal finger joint, a sign of osteoarthritis. They are not associated with infective endocarditis (IE).
Choice B rationale
Bouchard’s nodes are similar to Heberden’s nodes but occur at the proximal interphalangeal finger joint. They are also a sign of osteoarthritis and not associated with IE.
Choice C rationale
Janeway lesions are flat, painless, red or purple spots on the palms of the hands or the soles of the feet. They are associated with IE and are caused by septic emboli which are small clots filled with bacteria. These emboli can lodge in small blood vessels, causing these characteristic lesions.
Choice D rationale
Tophi are hard, uric acid deposits under the skin. They are a sign of chronic gout, not IE.

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In the context of interprofessional care of the client and family, where should a nurse position the stethoscope on the chest to assess a client’s apical heart rate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

You are providing care to a patient with pericarditis. Which of the following is NOT a proper nursing intervention for this patient?

Correct Answer is C

Explanation

The nurse is conducting a physical assessment on a client with infective endocarditis (IE). The nurse observes flat, reddened, non-tender maculae on the hands and feet. What does the nurse understand these to be?

Correct Answer is C

Explanation

The nurse is caring for a client with an acute myocardial infarction (AMI). What emergent procedure does the nurse anticipate the physician will order?

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What is the primary pathophysiological reason for performing Coronary Artery Bypass Surgery?

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