Which number marks the location where the nurse would auscultate the point of maximal impulse (PMI)?
1
2
3
4
5
The Correct Answer is A
The Point of Maximal Impulse (PMI), also referred to as the apical impulse, is the location on the chest wall where the heartbeat is most strongly felt or heard. It corresponds to the apex of the heart, typically located at the 5th intercostal space, midclavicular line in adults
Rationale for correct answers:
E. Near apex: This point corresponds to the 5th intercostal space at the midclavicular line, where the apex of the heart contacts the chest wall. It is the most accurate site for auscultating the apical pulse and evaluating left ventricular function.
Rationale for incorrect answers:
A. To the right of the aorta. This is in the right upper sternal border, typically used to auscultate the aortic valve area. It is not associated with the PMI or apex of the heart.
B. At left atrium: This is positioned more posteriorly in the chest and not palpable or auscultated directly from the anterior chest wall.
C. Placed slightly below 2: Still in the left parasternal area, likely over the pulmonic or tricuspid area, but not the apex.
D. Placed slightly below 3: This is near the left lower sternal border, where tricuspid sounds may be heard, but it's still not the apex.
F. At xiphoid process: This is the epigastric area, well below the heart’s apex, and is not used to assess apical pulse or PMI.
Take-home points:
- The PMI is best auscultated at the 5th intercostal space, midclavicular line, which corresponds to point 5 in the diagram.
- Accurate location of the PMI is essential in assessing left ventricular function and detecting cardiac enlargement or displacement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The Joint National Committee (JNC 7) report provides evidence-based guidelines for the classification and management of blood pressure (BP) to reduce the risk of cardiovascular disease.
Rationale for correct answer:
C. Stage 1 Hypertension: Stage 1 hypertension is defined as: Systolic 140–159 mmHg or Diastolic 90–99 mmHg.
Rationale for incorrect answers:
A. Normal: According to JNC 7, normal BP is defined as less than 120/80 mmHg.
B. Prehypertension is defined as: Systolic 120–139 mmHg or Diastolic 80–89 mmHg.
D. Stage 2 Hypertension is defined as: Systolic ≥160 mmHg or Diastolic ≥100 mmHg.
Take-home points:
- According to JNC 7, Stage 1 Hypertension is defined as a systolic BP of 140–159 mmHg or diastolic of 90–99 mmHg.
- When systolic and diastolic values fall into different categories, the higher stage should determine the classification.
Correct Answer is A
Explanation
According to the ANA and NCSBN guidelines, UAPs can take vital signs in stable clients, but the nurse is still responsible for interpreting the findings and taking action when needed. For clients who are unstable, newly admitted, or receiving high-risk treatments, vital signs should be taken by the nurse to allow for immediate clinical judgment.
Rationale for correct answer:
A. A client being prepared for elective facial surgery with a history of stable hypertension: This client is clinically stable and undergoing a planned, non-emergency procedure. The history of stable hypertension implies no acute instability, making it appropriate for the UAP to collect vital signs.
Rationale for incorrect answers:
B. A client receiving a blood transfusion with a history of transfusion reactions: This client is high risk due to a known history of transfusion reactions. Vital signs need to be monitored closely and frequently by a licensed nurse who can recognize early signs of a reaction.
C. A client recently started on a new antiarrhythmic agent: Starting a new antiarrhythmic introduces potential for serious adverse effects, including bradycardia, hypotension, or arrhythmias.
D. A client who is admitted frequently with asthma attacks: Although this client may be familiar to the unit, frequent asthma exacerbations place them at risk for acute respiratory deterioration. Vital signs should be taken by the nurse to assess signs of distress.
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