The nurse is preparing to assess the heart rate on an adult female client. The nurse recognizes that the apical pulse can be assessed in an adult female at which of the following anatomical position?
Fifth left intercostal space at the midclavicular line
Third left intercostal space at the midclavicular line
Fourth left intercostal space at the sternal border
Under the left breast at the midclavicular line
The Correct Answer is A
A. Fifth left intercostal space at the midclavicular line:
Explanation: The apical pulse, or the point of maximal impulse (PMI), is typically located at the fifth intercostal space at the midclavicular line on the chest. This is the area where the heartbeat is best heard using a stethoscope in most adults.
B. Third left intercostal space at the midclavicular line:
Explanation: This location is too high for the apical pulse. The heart's apex is generally not found at the third intercostal space; it's lower, closer to the fifth intercostal space.
C. Fourth left intercostal space at the sternal border:
Explanation: This location is not the typical site for auscultating the apical pulse. The PMI is usually heard at the midclavicular line, not at the sternal border.
D. Under the left breast at the midclavicular line:
Explanation: This position is not precise enough for auscultating the apical pulse. The specific intercostal space (fifth) and midclavicular line are crucial for accurate assessment.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Consists of two lobes.
This statement is correct. The left lung consists of two lobes: the upper lobe and the lower lobe. The right lung, not the left lung, has three lobes: upper, middle, and lower lobes.
B. Primarily consists of an upper lobe on the posterior chest.
This statement is not accurate. The upper lobe of the left lung is present in the anterior and posterior parts of the chest. It is not limited to the posterior chest.
C. Is shorter than the right lung because of the underlying stomach.
This statement is not correct. The left lung is not shorter due to the underlying stomach. The left lung is slightly smaller than the right lung to accommodate the space for the heart, but this size difference is not due to the stomach.
D. Is divided by the horizontal fissure.
This statement is not accurate. The left lung is not divided by the horizontal fissure. The horizontal fissure is a feature of the right lung, not the left lung. The left lung is divided by the oblique fissure into the upper and lower lobes

Correct Answer is C
Explanation
A. Bronchovesicular breath sounds and normal in that location:
Bronchovesicular breath sounds are medium-pitched sounds heard over the major bronchi and are usually equal on inspiration and expiration. They are typically heard in the 1st and 2nd intercostal spaces anteriorly and between the scapulae posteriorly. While they might be normal in certain locations, hearing them over peripheral lung fields might indicate an abnormality.
B. Normally auscultated over the trachea:
This statement doesn't specify a particular type of breath sound. Tracheal breath sounds are harsh and relatively high-pitched, heard directly over the trachea. They are normal over the trachea but are not normally heard in the lung periphery.
C. Vesicular breath sounds and normal in that location:
Vesicular breath sounds are low-pitched, soft sounds heard over most of the lungs during inspiration. They are longer on inspiration than expiration and are considered normal breath sounds heard in the peripheral lung fields. Hearing vesicular sounds in the posterior lower lobes is typical and indicates normal lung function.
D. Bronchial breath sounds and normal in that location:
Bronchial breath sounds are high-pitched and loud, heard primarily over the trachea and larynx. If heard in the peripheral lung fields, especially in the lower lobes, it can suggest an abnormality such as consolidation or compression of lung tissue.
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