A nurse is counting a client's apical pulse rate. Identify where the nurse should place the stethoscope to auscultate the apical pulse. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Answer and Explanation

The Correct Answer is "{\"xRanges\":[80.828125,100.828125],\"yRanges\":[129,149]}"

To auscultate the apical pulse, the nurse should place the stethoscope at the fifth intercostal space at the midclavicular line on the left side of the chest. This is the location of the apex of the heart, also referred to as the point of maximal impulse (PMI).

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Correct Answer is A

Explanation

A. A systolic murmur: A murmur heard between S1 and S2 occurs during systole, which is why it is classified as a systolic murmur. Systolic murmurs are often due to valve abnormalities like aortic stenosis or mitral regurgitation.

B. A third heart sound (S3): The S3 sound occurs after S2, not between S1 and S2. It is associated with rapid ventricular filling and may indicate heart failure.

C. A fourth heart sound (S4): The S4 sound occurs before S1, not between S1 and S2. It is associated with a stiff or hypertrophic ventricle.

D. An expected heart sound: A murmur is not considered an expected heart sound; it is typically abnormal and requires further investigation.

A. Check the client's distal pulses in both legs. B. Keep the client overnight. C. Restrict the client's oral fluids. D. Keep the client on bed rest for 12 hr.

Correct Answer is A

Explanation

A. Check the client's distal pulses in both legs. It is important to assess distal pulses to ensure adequate circulation and to detect any signs of potential complications, such as arterial occlusion or hematoma formation, after cardiac catheterization.

B. Keep the client overnight. Most clients do not need to be kept overnight after cardiac catheterization unless there are complications. This option is unnecessary in routine cases.

C. Restrict the client's oral fluids. Clients are encouraged to increase oral fluids after the procedure to help flush out the contrast dye used during the catheterization and reduce the risk of kidney damage.

D. Keep the client on bed rest for 12 hr. Bed rest is required for a few hours (typically 4-6 hours) after cardiac catheterization to reduce the risk of bleeding from the puncture site. However, 12 hours of bed rest is generally not necessary unless there are specific complications.

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A nurse is counting a client's apical pulse rate. Identify where the nurse should place the stethoscope to auscultate the apical pulse. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While auscultating a client's heart sounds, the nurse hears turbulence between S1 and S2. The nurse should document this finding as which of the following?

Correct Answer is A

Explanation

A nurse is assisting with the care of a client 2 hr postoperative following a cardiac catheterization. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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A nurse is counting a client's apical pulse rate. Identify where the nurse should place the stethoscope to auscultate the apical pulse. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

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