The nurse would palpate the axillae during examination of which area?

Anterior chest

Breasts

Heart

Neck

Answer and Explanation

The Correct Answer is B

A. Anterior chest: While the anterior chest examination is important, axillary palpation is more specific to the breast area.

B. Breasts: Palpation of the axillae is part of the breast examination to check for lymph nodes or masses.

C. Heart: The heart is assessed through auscultation and palpation of the chest, not the axillae.

D. Neck: The neck examination does not typically involve palpation of the axillae.

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Correct Answer is C

Explanation

A. S4 heart sound: An S4 heart sound is often associated with hypertensive heart disease or left ventricular hypertrophy, rather than congestive heart failure alone.

B. Harsh holosystolic murmur at the apex: This type of murmur is more indicative of mitral regurgitation rather than congestive heart failure.

C. S3 heart sound: An S3 heart sound is commonly associated with congestive heart failure, especially when there is volume overload and decreased left ventricular function.

D. Carotid bruits: Carotid bruits are associated with vascular issues rather than congestive heart failure.

A. Wait until the end of the physical assessment to reassess the radial pulse. B. Reassess the client's pedal pulse on the other foot. C. Assess the client's 51 and 52 sounds for regularity. D. Assess the client's apical pulse for a full minute.

Correct Answer is ["A","D"]

Explanation

A. Wait until the end of the physical assessment to reassess the radial pulse: If the radial pulse is irregular, it is important to reassess it to confirm irregularity. However, waiting until the end of the assessment is not recommended; it is better to reassess promptly.

B. Reassess the client's pedal pulse on the other foot: This is not related to assessing the regularity of the radial pulse.

C. Assess the client's 51 and 52 sounds for regularity: These terms are not standard in assessing pulse regularity; the focus should be on the apical pulse for an irregular radial pulse.

D. Assess the client's apical pulse for a full minute: The apical pulse should be assessed for a full minute to accurately determine the heart rate and rhythm, especially if the radial pulse is irregular.

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The nurse would palpate the axillae during examination of which area?

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Naxlex Comprehensive Predictor Exams

The nurse suspects an older adult client has congestive heart failure. Which of the following did the nurse most likely assess in the client?

Correct Answer is C

Explanation

During a physical assessment, the nurse should implement which actions initially when determining if a client's radial pulse is irregular? (Select all that apply.)

Correct Answer is ["A","D"]

Explanation

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