A nurse is collecting data from a client during a routine physical exam. Which of the following locations should the nurse identify as the point of maximum impulse?
A
B
C
The Correct Answer is A
Choice A: The fifth intercostal space at the midclavicular line
The point of maximal impulse (PMI), also known as the apical impulse, is usually located in the fifth intercostal space at the midclavicular line. This is the point on the precordium farthest outwards (laterally) and downwards (inferiorly) from the sternum at which the cardiac impulse can be felt.
Choice B: The first intercostal space at the sternal border
The first intercostal space at the sternal border is not typically the location of the PMI. The PMI is usually located in the fifth intercostal space at the midclavicular line.
Choice C: The second intercostal space at the sternal border
The second intercostal space at the sternal border is not typically the location of the PMI. The PMI is usually located in the fifth intercostal space at the midclavicular line.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: While a serum potassium level of 5 mEq/L is at the higher end of the normal range, the client is scheduled for dialysis, which should address the issue.
Choice B reason: Nausea after lithotripsy is a concern, but it may not be as urgent as other conditions.
Choice C reason: A pain level of 3 is manageable and not the highest priority compared to other more acute needs.
Choice D reason: A urine output of 80 mL over 8 hours is significantly low and could indicate acute kidney injury or urinary retention, which requires immediate attention.
Correct Answer is B
Explanation
Choice A reason: Sterile gloves should be donned after removing the old dressing and before handling the new sterile dressing.
Choice B reason: Offering pain medication before the procedure can help manage discomfort during the dressing change.
Choice C reason: Disinfecting the wound bed with alcohol is not recommended as it can damage new tissue and delay healing.
Choice D reason: Preparing sterile dressing supplies should be done just before the dressing change to maintain sterility.
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