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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Lordosis, or an exaggerated inward curve of the lumbar spine, is commonly seen in conditions such as obesity, pregnancy, or spinal abnormalities.
B. Osteoporosis typically leads to a more generalized loss of bone density, not a specific curvature.
C. Kyphosis involves an exaggerated outward curve of the upper back, not the lumbar spine.
D. Scoliosis is characterized by a lateral curvature of the spine, not an exaggerated lumbar curve.

A. the beginning of each shift. B. admission to the unit. C. discharge. D. the patient's wakening in the morning.

Correct Answer is A

Explanation

A. Performing a quick focused assessment at the beginning of each shift allows the nurse to identify any immediate needs or changes in the patient's condition, ensuring timely and appropriate care. This practice helps in maintaining continuity of care and promptly addressing any issues that may arise during the shift.
B. While a comprehensive assessment is typically performed upon admission to the unit, a quick focused assessment is not specifically required at this time. The initial comprehensive assessment will cover all necessary information.
C. At discharge, the focus is on providing discharge instructions and ensuring the patient understands their care plan after leaving the facility. A quick focused assessment is not typically performed at this time.
D. While it is important to check on the patient in the morning, a quick focused assessment is not specifically required at this time. The beginning of each shift is a more critical time to perform this assessment to ensure continuity of care.

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The nurse taking an apical pulse would place the stethoscope at:

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Naxlex Comprehensive Predictor Exams

The nurse notes that a patient has an exaggerated lumbar curve. This is indicative of

Correct Answer is A

Explanation

It is the responsibility of the nurse to perform a quick focused assessment of the patient upon:

Correct Answer is A

Explanation

When caring for a victim with a gunshot wound to the abdomen who has lost a significant amount of blood, the nurse would anticipate the vital signs to reflect:

When a fever begins to come down. the patient is in a state of

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When examining a patient's pupils with a light, the nurse notes that both pupils constrict, regardless of which eye is stimulated by the light. The nurse should document that the pupils exhibit:

The nurse would record a pulse as bradycardic if the rate were:

A patient who is terminally ill is described during shift report as having Cheyne-Stokes breathing. On assessment, the nurse anticipates finding: