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 ["A","B","C","D"]

Explanation

Choice A rationale
A 65-year-old male recovering from right lobectomy for treatment of lung cancer is at risk for developing sepsis. Post-surgical patients, especially those with cancer, are at increased risk due to potential infection at the surgical site and a weakened immune system from the cancer and/or its treatment.
Choice B rationale
A 78-year-old female with diabetes mellitus who is recovering from colon surgery is at risk for developing sepsis. Diabetes can impair the immune system, making it harder for the body to fight off infections. Additionally, any surgical procedure carries a risk of infection.
Choice C rationale
A 35-year-old female who is hospitalized with renal insufficiency and has a Foley catheter and central line in place is at risk for developing sepsis. Hospitalized patients, particularly those with invasive devices like catheters and central lines, are at increased risk due to potential introduction of bacteria into the body.
Choice D rationale
A 55-year-old male who is a recent kidney transplant recipient is at risk for developing sepsis. Transplant recipients are often on immunosuppressive therapy to prevent organ rejection, which can leave them more susceptible to infections.

A. A patient who experienced dizziness after the first dose of captopril. B. A patient exhibiting new-onset confusion, restlessness, and cool, clammy skin. C. A patient on oxygen therapy with bilateral crackles at the lung bases. D. A patient on IV nesiritide (Natrecor) with a blood pressure reading of 100/62.

Correct Answer is B

Explanation

Choice A rationale
While dizziness after the first dose of captopril can be concerning, it is not uncommon as the body adjusts to the medication. It is important to monitor this patient, but they are not the highest priority.
Choice B rationale
A patient exhibiting new-onset confusion, restlessness, and cool, clammy skin should be prioritized for assessment. These symptoms could indicate a serious condition such as shock or decreased cardiac output. This patient may be experiencing a rapid decline in condition and should be assessed immediately.
Choice C rationale
While a patient on oxygen therapy with bilateral crackles at the lung bases may have worsening heart failure, they are not the highest priority if they are stable. Crackles at the lung bases are a common finding in heart failure and indicate fluid accumulation in the lungs.
Choice D rationale
A patient on IV nesiritide (Natrecor) with a blood pressure reading of 100/62 is not the highest priority. While this blood pressure is on the lower side, it is not critically low.
Nesiritide can cause hypotension, so this patient should be monitored, but they are not the highest priority if they are stable.

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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’re providing care to four patients. Select all the patients who are at risk for developing sepsis:

Correct Answer is ["A","B","C","D"]

Explanation

Upon receiving a change-of-shift report about four patients in a heart failure unit, which patient should the nurse prioritize for assessment?

Correct Answer is B

Explanation

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