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
Explanation
A. Pushing the soles of the feet against the nurse's hands is a standard test to assess the strength of the lower extremities. It provides a clear indication of muscular strength and motor function.
B. Wiggling toes helps assess for sensation but does not evaluate overall strength or motor function in the lower extremities.
C. Pulling both feet up to stretch the Achilles tendons is not an appropriate method for assessing lower extremity strength.
D. Standing independently does not evaluate strength comprehensively and is more related to balance and coordination.
Correct Answer is D
Explanation
A. Hyperthermia refers to an abnormally high body temperature due to external factors or failure to regulate body heat, not necessarily a fever coming down.
B. Pyrexia is another term for fever and occurs when the body temperature is elevated due to an infection or other causes.
C. Hypothermia refers to dangerously low body temperature, which is not related to a fever resolving.
D. Defervescence refers to the process of a fever breaking, and the body temperature returning to normal as the fever resolves.
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