A nurse is assessing the apical heart rate of a healthy person. ...

[piesebel]

A nurse is assessing the apical heart rate of a healthy person. In order to hear the heart beats loud and clear, where should the nurse place the stethoscope?
 
  A) Slightly below the left nipple
  B) Over the sternum at the midpoint between the nipples
  C) Four inches below the left clavicle
  D) On the center of the rib cage

Question 2

A client in a health care facility has had a urinary catheter in situ for the past several days.The client's nurse has amended the client's plan of care to reflect the use of the device.
 
  What nursing diagnosis is a priority in this aspect of the client's care? A) Risk for deficient fluid volume
  B) Risk for infection
  C) Risk for impaired mobility
  D) Risk for acute pain

[CourtneyCNorton]

Answer to Question 1

A
Feedback:
The heart beats are best heard or felt in a healthy client slightly below the left nipple in line with the middle of the clavicle. The nurse does not place the stethoscope on the center of the rib cage, between the nipples, or 4 in. below the left clavicle to accurately assess the apical heart rate of a healthy person.

Answer to Question 2

B
Feedback:
Indwelling urinary catheters pose a high risk of infection; this risk must be addressed by providing meticulous nursing care. Catheters do not result in fluid volume deficit. The risk of infection is more likely a threat to the client than risks for pain and impaired mobility.

[piesebel]

Thanks

[CourtneyCNorton]

Welcome