In assessing the apical heart rate of an adult, in what order should the practical nurse (PN) perform the needed tasks?
Expose the left side of the chest.
Locate the point of maximal impulse.
Position the diaphragm of the stethoscope.
Listen for heart sounds.
The Correct Answer is A,B,C,D
A. Exposing the left side of the chest is the first step to access the area where the apical pulse is assessed. This step ensures that the nurse has clear access to the chest for auscultation.
B. Locating the point of maximal impulse (PMI) is the next step once the chest is exposed. The PMI, typically located at the 5th intercostal space at the midclavicular line, is where the heart’s apex is closest to the chest wall.
C. Positioning the diaphragm of the stethoscope on the PMI is the step where the actual auscultation begins. The diaphragm is used to listen for heart sounds.
D. Listening for heart sounds at the PMI is the final step to assess the apical heart rate. This step completes the assessment by allowing the PN to count the heart rate and evaluate the rhythm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. While postmenopausal use of herbal estrogen may be a risk factor for breast cancer, it is not as significant as having a family history of the disease.
B. A history of fibrocystic changes and a painful lump are not as strong a risk factor for breast cancer as a family history of the disease.
C. Being of normal weight, height, and having children at a younger age are generally considered protective factors rather than risk factors for breast cancer.
D. A non-tender lump combined with a family history of breast cancer (mother with breast cancer) is the most significant risk factor for developing breast cancer.
Correct Answer is B
Explanation
A. Isoniazid can cause side effects like peripheral neuropathy, but ringing in the ears is not a common symptom of this medication.
B. Gentamicin can cause ototoxicity, which includes symptoms such as ringing in the ears (tinnitus). This side effect is significant and should be reported to the healthcare provider for further evaluation.
C. Pyridoxine is used to prevent neuropathy caused by isoniazid and does not cause ringing in the ears.
D. Rifampin is an antitubercular medication but is not commonly associated with tinnitus as a side effect. The immediate concern with ringing in the ears is related to gentamicin.
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