The nurse taking an apical pulse would place the stethoscope at:
directly below the sternum.
the left of the sternum at the third intercostal space.
the left midclavicular line at the fifth intercostal space
tightly above the left nipple.
The Correct Answer is C
A. The area directly below the sternum is not the location for the apical pulse.
B. The third intercostal space is too high for the apical pulse, which is best heard at the fifth intercostal space.
C. The left midclavicular line at the fifth intercostal space is the proper location for auscultating the apical pulse.
D. Placing the stethoscope above the left nipple does not ensure accurate assessment of the apical pulse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. While extremity inspection is important, it is not as directly related to assessing back pain as evaluating the back itself.
B. Auscultating the lungs is essential in respiratory assessments but is not the priority when examining a patient with back pain.
C. Percussion of the flank areas is a key part of the physical examination for back pain, particularly if there are concerns of kidney involvement or other internal issues causing discomfort.
D. Bowel sounds are not directly related to back pain unless gastrointestinal issues are suspected.
Correct Answer is A
Explanation
A. Checking for normal, coordinated eye movement is key when assessing extraocular movements, which should be smooth and symmetric.
B. Pupillary dilation occurs under specific circumstances, such as low light, not necessarily when focusing on an object.
C. Blinking is a normal reflex but not a primary indicator when assessing extraocular movements.
D. Pupillary constriction is a separate function of the pupillary light reflex and not directly associated with extraocular movements.
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