The nurse is having difficulty hearing his patient’s apical pulse with his stethoscope. Which action will help the nurse hear the heartbeat more clearly?
Making sure that the earpieces fit loosely in the nurse’s ear canals
Utilizing a stethoscope with the longest possible tubing
Placing the diaphragm firmly against the patient’s skin
Positioning the bell very lightly over the patient’s sternum
The Correct Answer is C
Choice A reason: This is incorrect. Making sure that the earpieces fit loosely in the nurse’s ear canals will not help the nurse hear the heartbeat more clearly. Loose earpieces can let in ambient noise and reduce the sound quality.
Choice B reason: This is incorrect. Utilizing a stethoscope with the longest possible tubing will not help the nurse hear the heartbeat more clearly. Long tubing can reduce the sound transmission and create interference.
Choice C reason: This is correct. Placing the diaphragm firmly against the patient’s skin will help the nurse hear the heartbeat more clearly. The diaphragm is the flat circular part of the chest piece that is used to listen to low-pitched sounds, such as the heart. Firm pressure creates a good seal and blocks out external noise.
Choice D reason: This is incorrect. Positioning the bell very lightly over the patient’s sternum will not help the nurse hear the heartbeat more clearly. The bell is the small cup-shaped part of the chest piece that is used to listen to high-pitched sounds, such as the lungs. Light pressure is needed to avoid activating the diaphragm, but the sternum is not the best location to listen to the apical pulse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is an incorrect choice because exposure-related accident is not the type of error when the wrong type of medication is administered to the patient. Exposure-related accident is an incident that occurs when a person is exposed to a harmful substance or environment, such as radiation, chemicals, or extreme temperatures.
Choice B reason: This is the correct choice because procedure-related accident is the type of error when the wrong type of medication is administered to the patient. Procedure-related accident is an incident that occurs when a person is harmed by a medical or surgical procedure, such as a wrong-site surgery, a medication error, or a catheter infection.
Choice C reason: This is an incorrect choice because organization-related accident is not the type of error when the wrong type of medication is administered to the patient. Organization-related accident is an incident that occurs due to a failure of the system or the management of an organization, such as a lack of communication, a poor policy, or a staffing shortage.
Choice D reason: This is an incorrect choice because equipment-related accident is not the type of error when the wrong type of medication is administered to the patient. Equipment-related accident is an incident that occurs due to a malfunction or misuse of a device or a machine, such as a ventilator, a defibrillator, or a syringe.
Correct Answer is D
Explanation
Choice A reason: This is an incorrect choice because the patient has a history of noncompliance with prescribed therapeutic regimens is not a reason why this nursing diagnosis is considered to be a collaborative problem. A collaborative problem is a potential or actual health problem that requires the intervention of multiple health care professionals from different disciplines to achieve optimal patient outcomes. The patient's history of noncompliance is not related to the nature of the problem or the type of intervention required.
Choice B reason: This is an incorrect choice because the patient must be closely monitored in an intensive care unit is not a reason why this nursing diagnosis is considered to be a collaborative problem. A collaborative problem is a potential or actual health problem that requires the intervention of multiple health care professionals from different disciplines to achieve optimal patient outcomes. The patient's need for close monitoring is not related to the nature of the problem or the type of intervention required.
Choice C reason: This is an incorrect choice because prevention of septic shock is not a measurable patient outcome is not a reason why this nursing diagnosis is considered to be a collaborative problem. A collaborative problem is a potential or actual health problem that requires the intervention of multiple health care professionals from different disciplines to achieve optimal patient outcomes. The measurability of the patient outcome is not related to the nature of the problem or the type of intervention required.
Choice D reason: This is the correct choice because both nursing and physician-prescribed interventions are required is a reason why this nursing diagnosis is considered to be a collaborative problem. A collaborative problem is a potential or actual health problem that requires the intervention of multiple health care professionals from different disciplines to achieve optimal patient outcomes. The problem of septic shock is a complex and life-threatening condition that involves multiple organ systems and requires both medical and nursing interventions to prevent, treat, and monitor the patient's status.
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