The nurse assesses the client as shown. What pulse is the nurse assessing?

Posterior tibial

Femoral

Popliteal

Dorsalis pedis

Answer and Explanation

The Correct Answer is A

A. Posterior tibial: The posterior tibial pulse is palpated just behind the medial malleolus of the ankle, near the Achilles tendon.
B. Femoral: The femoral pulse is located in the groin area, where the femoral artery passes.
C. Popliteal: The popliteal pulse is palpated behind the knee in the popliteal fossa.
D. Dorsalis pedis: The dorsalis pedis pulse is located on the top of the foot, near the first metatarsal.

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Correct Answer is A

Explanation

A. I: A grade I murmur is very faint and may not be heard immediately without careful listening. The description of a murmur heard immediately upon placing the stethoscope indicates it is a grade I.

B. X: There is no grade X in the standard grading scale for heart murmurs.

C. II: A grade II murmur is quiet but easily heard with a stethoscope and would generally be more audible than described.

D. III: A grade III murmur is moderately loud and would be heard without difficulty. The description suggests a quieter murmur.

A. Bronchitis B. Heart failure C. Pneumonia D. Tuberculosis

Correct Answer is B

Explanation

A. Bronchitis primarily causes coughing and mucus production, and does not specifically relate to trouble breathing while lying down.

B. Heart failure often leads to orthopnea (difficulty breathing while lying flat) and paroxysmal nocturnal dyspnea (waking up at night with difficulty breathing). These symptoms align with the client's reported issues.

C. Pneumonia usually presents with acute symptoms such as cough, fever, and chest pain, rather than the specific nocturnal breathing difficulty described.

D. Tuberculosis typically involves symptoms like chronic cough, night sweats, and weight loss, rather than difficulty breathing while lying down.

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The nurse assesses the client as shown. What pulse is the nurse assessing?

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Naxlex Comprehensive Predictor Exams

During chest auscultation, the nurse hears a quiet murmur immediately upon placing the stethoscope on the client's chest. The nurse interprets this as which grade?

Correct Answer is A

Explanation

During a health history, a male client tells the nurse that he "can't breathe well" at night when he is lying down and has trouble sleeping because he wakes up with trouble breathing. The nurse would assess this client further for which of the following?

Correct Answer is B

Explanation

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