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.

Answer and Explanation

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.

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Correct Answer is ["A","D","E"]

Explanation

A. Oatmeal is a good choice for breakfast.
Oatmeal is a good source of iron and can be part of a vegetarian diet. It is a suitable option for increasing iron intake while adhering to vegetarian dietary restrictions.
B. Eat red meat just until the anemia is resolved.
This option is not suitable for a vegetarian client. Red meat is a source of heme iron, but it conflicts with the client’s dietary preferences and does not align with a vegetarian diet.
C. Take two prenatal vitamins with iron daily.
Doubling the dose of prenatal vitamins is not recommended without specific advice from a healthcare provider. The prescribed dosage should be followed, and dietary changes should be the focus.
D. Add lentils and black beans to soups.
Lentils and black beans are excellent sources of non-heme iron, which fits well within a vegetarian diet. Including these foods in meals can help boost iron levels effectively.
E. Increase green leafy vegetables in the diet.
Green leafy vegetables are high in non-heme iron and are suitable for vegetarians. Increasing their consumption supports iron intake and helps manage anemia.

A. Ask the client to tilt the head slightly toward the affected side. B. Position an emesis basin close to the neck under the ear. C. Pull the pinna of the ear in an upward and backward direction. D. Direct the flow of the warm solution toward the ear canal.

Correct Answer is B, A, C, D

Explanation

1. Warm the irrigation solution to body temperature to prevent dizziness or discomfort.

2. Position an emesis basin close to the neck under the ear to catch the returning solution and cerumen.

3. Ask the client to tilt the head slightly toward the affected side to allow the solution to flow easily into the ear canal.

4. Pull the pinna of the ear in an upward and backward direction to straighten the ear canal.

5. Direct the flow of the warm solution toward the wall of the ear canal, not directly at the eardrum, to dislodge the impacted cerumen gently.

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In assessing the apical heart rate of an adult, in what order should the practical nurse (PN) perform the needed tasks?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","D","E"]

Explanation

The practical nurse (PN) warms the irrigation solution before irrigating the ear of an adult client who has impacted cerumen in the ear canal. In which order should the PN implement these actions? (Arrange from first on top to last on the bottom.)

Correct Answer is B, A, C, D

Explanation

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