The nurse is preparing to assess a client's apical impulse. The nurse would palpate at which location?

Fourth intercostal space, left sternal border

Second intercostal space, left sternal border

Fifth intercostal space, left midclavicular line

Third intercostal space left axillary line

Answer and Explanation

The Correct Answer is C

C. Fifth intercostal space, left midclavicular line: The apical impulse, or point of maximal impulse (PMI), is typically palpated at the fifth intercostal space, left midclavicular line, where the apex of the heart is closest to the chest wall.

A. Fourth intercostal space, left sternal border: This location is not typically used for palpating the apical impulse; it is more relevant for auscultating heart sounds.

B. Second intercostal space, left sternal border: This location is used for auscultating the aortic and pulmonic valves.

D. Third intercostal space left axillary line: This is not a standard location for palpating the apical impulse.

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Correct Answer is C

Explanation

A. Antidepressant: Antidepressants are not typically associated with a high risk of thrombophlebitis.

B. Antihypertensive: Antihypertensives generally do not increase the risk of thrombophlebitis.

C. Oral contraceptive: Oral contraceptives are known to increase the risk of thrombophlebitis due to their effect on blood clotting factors.

D. Antilipid agent: Antilipid agents, such as statins, do not commonly cause thrombophlebitis.

A. Auscultate the anatomic area with a stethoscope. B. Use Doppler ultrasonography to locate the pulse. C. Ask another nurse to assess the pulse. D. Document absence of dorsalis pedis pulse.

Correct Answer is B

Explanation

A. Auscultating the area may not provide accurate information about the pulse if it is not palpable, though it can be part of the assessment if Doppler is unavailable.

B. Using Doppler ultrasonography is the most appropriate next step to accurately assess the pulse if it is not palpable, especially in older adults where pulses may be difficult to detect.

C. Asking another nurse to assess the pulse may not address the underlying issue of why the pulse is not palpable and does not provide additional information.

D. Documenting the absence of the dorsalis pedis pulse without further investigation could be premature, as Doppler ultrasonography should be used to confirm its absence.

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The nurse is preparing to assess a client's apical impulse. The nurse would palpate at which location?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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Correct Answer is B

Explanation

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