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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Orthostatic hypotension, a form of low blood pressure that happens when you stand up from sitting or lying down, would not typically cause severe chest pain or result in elevated levels of cardiac troponins I and T6.
Choice B rationale
Raynaud’s disease, a condition that causes some areas of your body — such as your fingers and toes — to feel numb and cold in response to cold temperatures or stress, would not typically cause severe chest pain or result in elevated levels of cardiac troponins I and T6.
Choice C rationale
Angina, a type of chest pain caused by reduced blood flow to the heart, could cause severe chest pain, but it would not typically result in elevated levels of cardiac troponins I and T6. Elevated troponin levels are more indicative of damage to the heart muscle, which is not characteristic of angina.
Choice D rationale
A myocardial infarction (MI), also known as a heart attack, could cause severe chest pain and would typically result in elevated levels of cardiac troponins I and T7. Troponins are proteins found in the heart muscle, and levels can rise in the blood when there is damage to the heart, such as during an MI.
Correct Answer is A
Explanation
Choice A rationale
Vasotec, an Angiotensin-Converting Enzyme (ACE) inhibitor, is commonly used to treat conditions like high blood pressure and heart failure. It works by relaxing blood vessels, which allows blood to flow more easily and reduces blood pressure.
Choice B rationale
Decreased urine output is not a typical outcome of taking Vasotec. In fact, ACE inhibitors like Vasotec can sometimes increase urine output by improving kidney function.
Choice C rationale
Increased appetite is not a known effect of Vasotec. If a patient experiences a significant change in appetite while taking this medication, they should consult their healthcare provider.
Choice D rationale
Increased fluid retention is not a typical outcome of taking Vasotec. ACE inhibitors like Vasotec are often used to help reduce fluid retention in patients with conditions like heart failure.
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