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

right upper sternal border

left upper sternal border

left lower sternal border

5th intercostal space, midclavicular line

Answer and Explanation

The Correct Answer is {"xRanges":[234.765625,254.765625],"yRanges":[107.609375,127.609375]}

A.   The right upper sternal border is not the correct placement for auscultating the apical pulse. This location is more appropriate for assessing heart sounds related to the aortic valve.
B.   The left upper sternal border is not the correct placement for auscultating the apical pulse.
This location is more appropriate for assessing heart sounds related to the pulmonic valve.
C.   The left lower sternal border is not the correct placement for auscultating the apical pulse.
This location is more appropriate for assessing heart sounds related to the tricuspid valve.
D.   5th intercostal space, midclavicular line is the correct placement for auscultating the apical pulse. This location corresponds to the apex of the heart, which is where the apical pulse (also known as the point of maximum impulse or PMI) can be best heard.

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Correct Answer is D

Explanation

A. Contacting the pharmacy might be a good step in some cases, but if the nurse has identified a dosage that is three times higher than usual, it's crucial to address this directly with the prescribing provider first.
B. Asking another nurse to verify is a reasonable step, but ultimately, it's the responsibility of the nurse who identifies the discrepancy to take action.
C. Informing the charge nurse and administering the dose without questioning the provider's order could potentially put the client at risk if the dosage is indeed too high.
D. Contacting the provider to question the dosage is the most appropriate immediate action. It's crucial to seek clarification from the provider regarding the unusually high dosage to ensure the safety and well-being of the client. This step ensures that the client receives the correct and safe medication dosage.

A. One nurse lifting as the client pushes with his feet B. Two nurses lifting the client under the shoulders C. Two nurses using a friction-reducing device D. One nurse lifting the client's legs as the client uses a trapeze bar

Correct Answer is C

Explanation

A. Having one nurse lift as the client pushes with his feet may not provide enough support and could potentially lead to an unsafe transfer, especially if the client is only partially able to assist.
B. Lifting the client under the shoulders with the assistance of another nurse may be appropriate for a different type of transfer, such as a sit-to-stand transfer, but it may not be the most suitable method for moving the client up in bed.
C. When a client is only partially able to assist, using a friction-reducing device, such as a slide or transfer board, is an effective and safe method. This device helps reduce the
friction between the client and the bed, making it easier to move the client up in bed.
D. Using a trapeze bar requires the client to have a certain level of strength and mobility, and may not be suitable for a client who is only partially able to assist.

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A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the client's 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

When reviewing the admitting prescriptions for a client, the nurse notes that the dose of one medication is three times the usual dose of this medication. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is preparing to move a client who is only partially able to assist up in bed. Which of the following methods should the nurse plan to use?

Correct Answer is C

Explanation

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