When assessing the heart, the nurse inspects and palpitates which of the following?
Peritoneum and tricuspid area
Precordium and PMI
Precordium and apical heart rate
Peritoneum and left sternal border.
The Correct Answer is B
When assessing the heart, the nurse will inspect and palpate the precordium, which is the area of the chest overlying the heart, and the PMI (point of maximal impulse), which is the point on the chest where the heartbeat is the strongest. These assessments allow the nurse to gather information about the size, shape, and location of the heart and to detect any abnormalities in the heartbeat or rhythm. The peritoneum is a membrane lining the abdominal cavity and has no relevance in the assessment of the heart. The tricuspid area and left sternal border are areas of the chest that may be auscultated to assess heart sounds but are not palpated during a heart assessment.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Auscultating breath sounds is an essential component of a respiratory assessment. The following breath sounds can be heard during auscultation: Vesicular, Bronchial, Bronchovesicular, Crackles, Wheezes, and Rhonchi.
Vesicular sounds at the apex of the lungs (a) and vesicular sounds at the base of the lungs on the posterior chest (c) are normal findings. Vesicular sounds are soft and low-pitched, heard during inspiration, and are indicative of air moving through small airways and alveoli. The vesicular sounds are louder at the base of the lungs, where there is more alveolar tissue.
Rhonchi that disappear with coughing (d) can be normal or abnormal findings. Rhonchi are low-pitched, continuous sounds that are heard during inspiration and expiration. They are produced by the movement of air through narrowed or obstructed airways. If the rhonchi disappear with coughing, it may indicate that the airway has cleared.
Wheezes on inspiration (b) are abnormal findings and require prompt follow-up. Wheezes are high-pitched, whistling sounds heard during inspiration and expiration. They are indicative of air moving through narrowed airways and can be a sign of an underlying respiratory condition such as asthma, chronic obstructive pulmonary disease (COPD), or bronchitis. Prompt follow-up is necessary to diagnose and manage the underlying condition.

Correct Answer is C
Explanation
When a patient is admitted with a complaint of chest pain, the priority assessment would be to determine whether the patient is experiencing an acute cardiac event, such as a heart attack. This would involve a comprehensive assessment that includes obtaining the patient's medical history, vital signs (blood pressure, heart rate, respiratory rate, oxygen saturation), performing a physical exam, and obtaining an electrocardiogram (ECG).
Other important factors to assess include the location and nature of the pain, any associated symptoms (such as shortness of breath or diaphoresis), the patient's current medications and medical history (including any history of heart disease or risk factors), and any recent procedures or interventions that may have led to the current presentation.
Prompt assessment and intervention are crucial in managing a patient with chest pain, as timely treatment can help to minimize damage to the heart muscle and prevent further complications. Therefore, any signs of an acute cardiac event should be immediately reported to the healthcare provider in charge, and appropriate interventions should be initiated promptly.

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