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 ["A","B","D"]
Explanation
A persistent cough can indicate lung cancer or other types of cancer affecting the respiratory system, making it a warning sign that should be noted.
B. Difficulty swallowing, or dysphagia, can be indicative of cancer in the esophagus, throat, or mouth, and should raise concern when observed.
C. Changes in pulse rate are typically not direct indicators of cancer; however, they could result from underlying conditions related to cancer treatment or progression.
D. An obvious change in a mole, especially in size, shape, or color, is a well-known warning sign of skin cancer, specifically melanoma.
E. Vesicular breath sounds are normal breath sounds, not linked to cancer.
F. Hyperactive bowel sounds could indicate a gastrointestinal issue but are not specific to cancer.
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.
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