In the context of interprofessional care of the client and family, where should a nurse position the stethoscope on the chest to assess a client’s apical heart rate?

On the left side at the midclavicular line, fifth intercostal space.

Directly over the heart on the sternum.

On the right side at the midclavicular line, fourth intercostal space.

At the midaxillary level on the left side.

Answer and Explanation

The Correct Answer is A

Choice A rationale
The apical pulse, also known as the point of maximal impulse (PMI), is located at the fifth intercostal space at the left midclavicular line. This is the location where the heartbeat is strongest and is the standard location for assessing the apical heart rate.
Choice B rationale
Placing the stethoscope directly over the heart on the sternum is not the standard method for assessing the apical heart rate. While the sternum is close to the heart, it is not the location where the heartbeat is strongest or most easily heard.
Choice C rationale
The right side at the midclavicular line, fourth intercostal space, is not the standard location for assessing the apical heart rate. The heart is located more towards the left side of the chest, and the apical pulse is typically not as easily heard on the right side.
Choice D rationale
The midaxillary line on the left side is not the standard location for assessing the apical heart rate. While this location is on the left side of the chest, it is not where the heartbeat is strongest or most easily heard.

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

Explanation

Choice A rationale
Weight loss is often recommended as a first-line therapeutic approach to lowering blood pressure in patients diagnosed with essential hypertension. Excess weight can increase the strain on the heart and blood vessels, leading to higher blood pressure.
Choice B rationale
Regular physical activity is another important part of managing hypertension. Exercise can help lower blood pressure by improving heart health and reducing weight.
Choice C rationale
Beta-blockers, such as propranolol, are a type of medication used to treat hypertension. However, they are not typically the first choice for initial therapy unless the patient has a specific indication for this class of medication, such as heart failure or angina.
Choice D rationale
Decreasing sodium intake is another lifestyle change that can help lower blood pressure. Consuming too much sodium can cause the body to retain fluid, which can increase blood pressure.
Choice E rationale
Smoking cessation is also recommended for patients with hypertension. While smoking does not directly cause high blood pressure, it can damage blood vessels and increase the risk of heart disease.

A. The patient should take the digoxin if their pulse is below 60 beats/min. B. The patient should notify the health care provider if they develop nausea. C. The patient should limit their dietary intake of potassium. D. The patient should take the hydrochlorothiazide at bedtime.

Correct Answer is B

Explanation

Choice A rationale
Digoxin slows the heart rate and increases the force of heart contractions, which can be beneficial in heart failure. However, if the pulse is below 60 beats/min, taking digoxin could further slow the heart rate and potentially lead to bradycardia.
Choice B rationale
Nausea can be a side effect of digoxin and hydrochlorothiazide. If the patient develops nausea, they should notify their healthcare provider as this could indicate that the medication dose needs adjustment.
Choice C rationale
Hydrochlorothiazide can cause the body to lose potassium, so limiting dietary intake of potassium could potentially lead to hypokalemia, a condition characterized by low potassium levels in the blood.
Choice D rationale
Taking hydrochlorothiazide at bedtime could potentially lead to nocturia, which is the need to wake up at night to urinate. This could disrupt the patient’s sleep.

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In the context of interprofessional care of the client and family, where should a nurse position the stethoscope on the chest to assess a client’s apical heart rate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is included in the first-line therapeutic approach to lowering blood pressure in a patient diagnosed with essential hypertension? (Select all that apply)

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

Explanation

In the context of Interprofessional Care of the Client and Family Across the Lifespan, a nurse is planning discharge teaching for a patient with chronic heart failure who has been prescribed digoxin (Lanoxin) and hydrochlorothiazide. What instruction should the nurse include in the teaching?

Correct Answer is B

Explanation

A patient with heart failure has recently started taking Digoxin (Lanoxin), Furosemide (Lasix), and Captopril. Which finding by the home health nurse is a priority to communicate to the healthcare provider?

A patient with angina pectoris is experiencing chest pain at rest and needs to take three nitroglycerin (NTG) pills to relieve the pain. What should the nurse consider this as a major symptom of?

A client is admitted to the telemetry unit due to an episode of substernal chest pain. Diagnostic tests reveal an elevated ST segment on the electrocardiogram (ECG) and an increased cardiac troponin level. What would be an appropriate initial nursing intervention?

Which of the following conditions are potential causes of secondary hypertension? (Select all that apply)

Diltiazem (Cardizem) has been prescribed for a patient newly diagnosed with Prinzmetal’s (variant) angina. What accurate action of diltiazem should the nurse include in the teaching plan?

While admitting a patient with pericarditis, what manifestations of this disorder should the nurse assess for?

The nurse is reviewing the laboratory test results for a patient who has recently been diagnosed with hypertension. Which result is most important to communicate to the health care provider?