A patient with heart failure is one-day postoperative for major abdominal surgery. When the nurse and the assistive personnel raise the head of the bed to sit the patient on the side of the bed before ambulation, the patient immediately complains of dizziness and nausea. What are your immediate actions? Select all that apply

The Point of Maximal Impulse (PMI), also referred to as the apical impulse, is the location on the chest wall where the heartbeat is most strongly felt or heard. It corresponds to the apex of the heart, typically located at the 5th intercostal space, midclavicular line in adults

Rationale for correct answers:

E. Near apex: This point corresponds to the 5th intercostal space at the midclavicular line, where the apex of the heart contacts the chest wall. It is the most accurate site for auscultating the apical pulse and evaluating left ventricular function.

Rationale for incorrect answers:

A. To the right of the aorta. This is in the right upper sternal border, typically used to auscultate the aortic valve area. It is not associated with the PMI or apex of the heart.

B. At left atrium: This is positioned more posteriorly in the chest and not palpable or auscultated directly from the anterior chest wall.

C. Placed slightly below 2: Still in the left parasternal area, likely over the pulmonic or tricuspid area, but not the apex.

D. Placed slightly below 3: This is near the left lower sternal border, where tricuspid sounds may be heard, but it's still not the apex.

F. At xiphoid process: This is the epigastric area, well below the heart’s apex, and is not used to assess apical pulse or PMI.

Take-home points:

• The PMI is best auscultated at the 5th intercostal space, midclavicular line, which corresponds to point 5 in the diagram.
• Accurate location of the PMI is essential in assessing left ventricular function and detecting cardiac enlargement or displacement.

According to guidelines like JNC 7 and ACC/AHA, consistent elevated readings over multiple visits are necessary to diagnose hypertension. Nurses play a vital role in recognizing abnormal readings, educating patients, and guiding appropriate follow-up to prevent long-term complications like stroke or heart disease.

Rationale for correct answer:

A. Follow-up measurements of blood pressure: A single elevated BP does not confirm a diagnosis of hypertension. The nurse should recommend rechecking BP on separate occasions, as per guidelines, to determine if the elevation is persistent.

Rationale for incorrect answers:

B. Immediate treatment by a physician: Immediate treatment is not warranted based on a single mildly elevated BP unless the patient is symptomatic or has evidence of organ damage.

C. Nothing, because the nurse considers this reading is due to anxiety: While anxiety (white-coat hypertension) may cause temporary elevation, it should not be assumed without confirmation.

D. A change in dietary intake: Dietary changes (e.g., low sodium, DASH diet) are important in preventing or managing hypertension. However, before prescribing lifestyle changes, the first step is to confirm whether BP is consistently elevated.

Take-home points:

• A single reading of 130/90 mm Hg should prompt follow-up measurements, not immediate diagnosis or treatment.
• Nurses should avoid assumptions and use evidence-based protocols to guide BP assessment and education.