The nurse taking an apical pulse would place the stethoscope at:

directly below the sternum.

the left of the sternum at the third intercostal space.

the left midclavicular line at the fifth intercostal space

tightly above the left nipple.

Answer and Explanation

The Correct Answer is C

A.   The area directly below the sternum is not the location for the apical pulse.
B.   The third intercostal space is too high for the apical pulse, which is best heard at the fifth intercostal space.
C.   The left midclavicular line at the fifth intercostal space is the proper location for auscultating the apical pulse.
D.   Placing the stethoscope above the left nipple does not ensure accurate assessment of the apical pulse.

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Correct Answer is A

Explanation

A. Allowing the patient to sit on the side of the bed helps to prevent sudden drops in blood pressure and allows the body to adjust to the change in position, reducing the risk of fainting or dizziness.
B. Using a wheelchair for mobility may not address the root cause of orthostatic hypotension and may limit the patient's independence.
C. Keeping the patient in a high Fowler's position could worsen the symptoms of orthostatic hypotension.
D. Rising quickly could lead to a sudden drop in blood pressure and increase the risk of a fall or injury.

A. check the patient's record to determine his baseline blood pressure. B. notify the charge nurse of the hypotension. C. check medications that might be the cause of the irregularity. D. notify the doctor of the bradycardia.

Correct Answer is A

Explanation

A. This is because the patient's blood pressure of 98/66 mm Hg, while on the lower side, may be normal for them. It's important to compare it to their baseline to determine if there has been a significant change.
B. The blood pressure is within a normal range for an adult, so immediate notification of hypotension is not required.
C. This can be done after determining if there is a significant change from the baseline.
D. The pulse is not bradycardic (it is within a normal range), so there is no immediate need to notify the doctor regarding bradycardia.

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The nurse taking an apical pulse would place the stethoscope at:

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Naxlex Comprehensive Predictor Exams

Because the older adult's blood vessels are nonelastic, they are prone to orthostatic hypotension. A priority intervention for a patient with orthostatic hypotension is to:

Correct Answer is A

Explanation

A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing intervention is to:

Correct Answer is A

Explanation

The nurse taking an apical pulse would place the stethoscope at:

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