The nurse is preparing to assess the heart rate on an adult female client. The nurse recognizes that the apical pulse can be assessed in an adult female at which of the following anatomical position?

Fifth left intercostal space at the midclavicular line

Third left intercostal space at the midclavicular line

Fourth left intercostal space at the sternal border

Under the left breast at the midclavicular line

Answer and Explanation

The Correct Answer is A

A. Fifth left intercostal space at the midclavicular line:

Explanation: The apical pulse, or the point of maximal impulse (PMI), is typically located at the fifth intercostal space at the midclavicular line on the chest. This is the area where the heartbeat is best heard using a stethoscope in most adults.

B. Third left intercostal space at the midclavicular line:

Explanation: This location is too high for the apical pulse. The heart's apex is generally not found at the third intercostal space; it's lower, closer to the fifth intercostal space.

C. Fourth left intercostal space at the sternal border:

Explanation: This location is not the typical site for auscultating the apical pulse. The PMI is usually heard at the midclavicular line, not at the sternal border.

D. Under the left breast at the midclavicular line:

Explanation: This position is not precise enough for auscultating the apical pulse. The specific intercostal space (fifth) and midclavicular line are crucial for accurate assessment.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. A shiny, pearly white color tympanic membrane: This is a normal finding. A healthy tympanic membrane often appears shiny and pearly white.

B. The presence of cerumen: This is a normal finding. Cerumen, or earwax, is a natural substance that helps protect the ear canal.

C. The presence of a cone of light: This is a normal finding. The cone of light is a reflection of the otoscope light on the tympanic membrane and is a normal variation.

D. A yellow or amber color to the tympanic membrane: This is considered an abnormal finding. A yellow or amber coloration of the tympanic membrane can indicate the presence of fluid or infection behind the eardrum, which may be a sign of otitis media or other ear conditions.

A. A slight asymmetry in breast size can be expected B. Asymmetry of breast size and shape is probably due to breastfeeding and is nothing to worry about. C. A sudden uneven increase in breast size is normal in adults D. Breasts should always be symmetric.

Correct Answer is A

Explanation

A. A slight asymmetry in breast size can be expected: This response is accurate. It acknowledges the natural variation in breast size that many women experience. It's common for one breast to be slightly larger or shaped differently than the other. It assures the client that this asymmetry is normal and not a cause for concern.

B. Asymmetry of breast size and shape is probably due to breastfeeding and is nothing to worry about: While breastfeeding can cause temporary changes in breast size and shape, not all cases of breast asymmetry are related to breastfeeding. This statement might not cover all situations, making it less accurate.

C. A sudden uneven increase in breast size is normal in adults: This statement is not accurate. Sudden changes in breast size should always be investigated, as they can indicate underlying health issues and may not be considered normal.

D. Breasts should always be symmetric: This statement is not accurate. Perfect symmetry in breast size and shape is rare. Most women have some degree of asymmetry, which is entirely normal. It's important to reassure the client that slight differences are common and not a cause for concern.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is preparing to assess the heart rate on an adult female client. The nurse recognizes that the apical pulse can be assessed in an adult female at which of the following anatomical position?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse examines a client's auditory canal and tympanic membrane with an otoscope. The nurse recognizes that which of the following is considered an abnormal finding?

Correct Answer is D

Explanation

The nurse is performing a breast exam on a client. The client asks the nurse why the left breast is slightly larger than the right breast. Which of the following should be the appropriate response by the nurse?

Correct Answer is A

Explanation

The nurse is doing an assessment of an adult client and noticed unequal chest expansion. The nurse recognizes that unequal chest expansion occurs:

The nurse is assessing the carotid arteries of a client with cardiovascular disease. What action should be performed next by the nurse?

The nurse is preparing to measure the visual acuity of a client. The nurse should recognize that which of the following cranial nerve should be assessed:

A nurse is reviewing the anatomy and physiologic functioning of the heart. The nurse should recognize that which statement best describes the atrial kick?

The nurse is listening to the breath sounds of young adult client with severe asthma. The nurse recognizes that air passing through narrowed bronchioles would produce which of these adventitious sounds?

A client diagnosed with pleuritis has been admitted to the hospital and complains of pain with breathing. Which of the following assessment findings should the nurse expect when auscultating a client with pleuritis?

The nurse is auscultating heart sounds on a client and hears an extra sound late in diastole, just before the S1. How should the nurse document this finding?