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 D
Explanation
A. A shiny, pearly white color tympanic membrane: This is a normal finding. A healthy tympanic membrane often appears shiny and pearly white.
B. The presence of cerumen: This is a normal finding. Cerumen, or earwax, is a natural substance that helps protect the ear canal.
C. The presence of a cone of light: This is a normal finding. The cone of light is a reflection of the otoscope light on the tympanic membrane and is a normal variation.
D. A yellow or amber color to the tympanic membrane: This is considered an abnormal finding. A yellow or amber coloration of the tympanic membrane can indicate the presence of fluid or infection behind the eardrum, which may be a sign of otitis media or other ear conditions.
Correct Answer is D
Explanation
A. When bronchial breath sounds are auscultated in the trachea.
Auscultating bronchial breath sounds in the trachea is a normal finding, as the trachea is close to the upper airway, and this is where bronchial sounds are normally heard. However, if these sounds are heard in the peripheral lung fields, it can indicate an abnormal condition.
B. When the client is experiencing excessive sneezing from a tree pollen allergy.
Excessive sneezing due to allergies would not typically result in increased breath sounds. Allergies may cause nasal congestion, but they don't directly lead to increased breath sounds.
C. When the client is resting in bed and not experiencing respiratory issues.
If a client is at rest and not experiencing any respiratory issues, breath sounds should typically be normal. There would be no reason to expect increased breath sounds in this scenario.
D. When the bronchial tree is obstructed by secretions.
Increased breath sounds, such as wheezing or rhonchi, can be auscultated when there is an obstruction in the bronchial tree due to secretions, narrowing of the airways, or other causes. These sounds are typically abnormal and indicate an issue with air movement through the airways.
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