Author Question: Where would the nurse place the head of the stethoscope when assessing an apical pulse? a. Third ... (Read 83 times)

Chloeellawright · **on:** Jul 11, 2018

Where would the nurse place the head of the stethoscope when assessing an apical pulse?

a. Third intercostal space at proximal edge of the clavicle
b. Fourth intercostal space at the edge of the sternum
c. Fifth intercostal space even with the middle of the clavicle
d. Sixth intercostal space above the diaphragm

Question 2

The nurse conducting a patient assessment records a seated blood pressure of 135/86. What standing blood pressure would be indicative of orthostatic hypotension?

a. 145/85
b. 134/76
c. 130/72
d. 124/62

connor417 · **Reply #1 on:** Jul 11, 2018

Answer to Question 1

ANS: C
The correct placement of the stethoscope for the assessment of the apical pulse is at the fifth intercostal space at the midclavicular line. The pulse should be counted for a full minute.

Answer to Question 2

ANS: D
Orthostatic hypotension is suspected when the systolic reading is 20 mm Hg lower than the sitting blood pressure. Dizziness with a diastolic pressure less than 100 mm Hg should also be reported.