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

Explanation

Choice A rationale
Clubbed fingers can be a symptom of conditions such as endocarditis, a heart condition that involves inflammation of the inner lining of the heart.
Choice B rationale
While myocardial infarction (heart attack) is a serious condition, it is not typically associated with clubbing of the fingers.
Choice C rationale
Acute kidney injury does not typically cause clubbing of the fingers.
Choice D rationale
Chronic thrombophlebitis, a condition characterized by inflammation and blood clots in the veins, is not typically associated with clubbing of the fingers.

A. Newly admitted patient with a BP of 150/87 mm Hg. B. Patient with left ventricular failure who has a BP of 110/70 mm Hg. C. Postoperative patient with a BP of 116/42 mm Hg. D. Patient with a myocardial infarction who has a BP of 140/86 mm Hg.

Correct Answer is C

Explanation

The patient with a blood pressure of 116/42 mm Hg has a mean arterial pressure (MAP) of approximately 67 mm Hg, which is less than the standard policy of 70 mm Hg. This could indicate inadequate blood flow to the vital organs, necessitating notification of the healthcare provider.

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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

While conducting an admission assessment, the nurse observes clubbing of the patient’s fingers. Based on this finding, the nurse should he patient about which disease process?

Correct Answer is A

Explanation

The standard policy on the cardiac unit states, “Notify the health care provider for mean arterial pressure (MAP) less than 70 mm Hg.”. Which patient should the nurse call the health care provider about?

Correct Answer is C

Explanation

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