While conducting an admission assessment, the nurse observes clubbing of the patient’s fingers. Based on this finding, the nurse should he patient about which disease process?

Endocarditis.

Myocardial infarction.

Acute kidney injury.

Chronic thrombophlebitis.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Clubbed fingers can be a symptom of conditions such as endocarditis, a heart condition that involves inflammation of the inner lining of the heart.
Choice B rationale
While myocardial infarction (heart attack) is a serious condition, it is not typically associated with clubbing of the fingers.
Choice C rationale
Acute kidney injury does not typically cause clubbing of the fingers.
Choice D rationale
Chronic thrombophlebitis, a condition characterized by inflammation and blood clots in the veins, is not typically associated with clubbing of the fingers.

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Correct Answer is D

Explanation

Choice A rationale
Aortic regurgitation is a condition where the aortic valve doesn’t close tightly, causing blood to leak back into the left ventricle. This condition can lead to left heart failure but is not typically associated with right heart failure.
Choice B rationale
Mitral regurgitation is a disorder in which the mitral valve on the left side of the heart does not close properly. This condition can lead to left heart failure but is not typically associated with right heart failure.
Choice C rationale
Aortic stenosis is a narrowing of the aortic valve opening. This condition can lead to left heart failure but is not typically associated with right heart failure.
Choice D rationale
Tricuspid regurgitation is a disorder in which the heart’s tricuspid valve does not close properly, causing blood to flow backward into the right atrium. This condition can lead to right heart failure, especially when associated with pulmonary hypertension.

A. On the left side at the midclavicular line, fifth intercostal space. B. Directly over the heart on the sternum. C. On the right side at the midclavicular line, fourth intercostal space. D. At the midaxillary level on the left side.

Correct Answer is A

Explanation

Choice A rationale
The apical pulse, also known as the point of maximal impulse (PMI), is located at the fifth intercostal space at the left midclavicular line. This is the location where the heartbeat is strongest and is the standard location for assessing the apical heart rate.
Choice B rationale
Placing the stethoscope directly over the heart on the sternum is not the standard method for assessing the apical heart rate. While the sternum is close to the heart, it is not the location where the heartbeat is strongest or most easily heard.
Choice C rationale
The right side at the midclavicular line, fourth intercostal space, is not the standard location for assessing the apical heart rate. The heart is located more towards the left side of the chest, and the apical pulse is typically not as easily heard on the right side.
Choice D rationale
The midaxillary line on the left side is not the standard location for assessing the apical heart rate. While this location is on the left side of the chest, it is not where the heartbeat is strongest or most easily heard.

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While conducting an admission assessment, the nurse observes clubbing of the patient’s fingers. Based on this finding, the nurse should he patient about which disease process?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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