The nurse is assessing the apical pulse. Where should the stethoscope be placed?
Between the fourth and fifth intercostal space.
Between the third and fourth intercostal space.
Between the second and third intercostal space.
Between the first and second intercostal space.
The Correct Answer is A
Choice A rationale
The apical pulse is located at the fifth intercostal space at the left midclavicular line.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Insisting that family members provide most of the client’s personal care may not be culturally appropriate. It may place undue burden on the family and may not respect the client’s autonomy or preferences.
Choice B rationale
Maintaining a personal space of at least 2 feet when assessing the client may not be culturally appropriate. Different cultures have different norms and expectations about personal space, and this distance may be seen as too distant or impersonal in some cultures.
Choice C rationale
Asking permission before touching a client during the physical assessment is a culturally appropriate nursing intervention. It shows respect for the client’s personal space and autonomy, and acknowledges cultural differences in norms about touch.
Choice D rationale
Considering the client’s ethnicity as the most important factor in planning care is not a culturally appropriate nursing intervention. While a client’s ethnicity can influence their health beliefs and behaviors, it is only one aspect of their identity and should not be the sole basis for planning care. Hildegard Peplau Hildegard Peplau Explore
Correct Answer is D
Explanation
Choice A rationale
Respiratory acidosis is characterized by a pH less than 7.35 and a PaCO2 greater than 454. In this case, the pH is 7.43, which is within the normal range, and the PaCO2 is 46, which is slightly above the normal range. Therefore, this does not indicate respiratory acidosis.
Choice B rationale
Respiratory alkalosis is characterized by a pH greater than 7.45 and a PaCO2 less than 354. In this case, the pH is 7.43, which is within the normal range, and the PaCO2 is 46, which is slightly above the normal range. Therefore, this does not indicate respiratory alkalosis.
Choice C rationale
Metabolic acidosis is characterized by a pH less than 7.35 and a HCO3 less than 224. In this case, the pH is 7.43, which is within the normal range, and the HCO3 is 35, which is above the normal range. Therefore, this does not indicate metabolic acidosis.
Choice D rationale
Metabolic alkalosis is characterized by a pH greater than 7.45 and a HCO3 greater than 264. In this case, the pH is 7.43, which is within the normal range, and the HCO3 is 35, which is above the normal range. Therefore, this indicates metabolic alkalosis.
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