Author Question: The client's apical pulse will be taken by a student. According to the nurse the stethoscope should ... (Read 87 times)

Mimi

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The client's apical pulse will be taken by a student. According to the nurse the stethoscope should be placed along the left clavicular line at the:
 
  1. Second to third intercostal space
  2. Third to fourth intercostal space
  3. Fourth to fifth intercostal space
  4. Fifth to sixth intercostal space

Question 2

A spouse assists the nurse evaluating the measurement of the client's blood pressure. The nurse feels additional teaching is required if the spouse is observed:
 
  1. Deflating the cuff at 2 mm Hg/second
  2. Having the client sit down for the measurement
  3. Using the same time each day for the measurement
  4. Taking the blood pressure after the client comes back from a walk



Perkypinki

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Answer to Question 1

ANS: 3
An apical pulse should be assessed at the client's PMI. The PMI is located at the fourth to fifth intercostal space at the left midclavicular line. Second to third intercostals space is not the correct placement for auscultating a client's apical pulse. The PMI is higher and more medial in children under 8 years old, thus the third to fourth is incorrect. The client is not identified as being a child.
Fifth to sixth is not the correct placement for auscultating a client's apical pulse.

Answer to Question 2

ANS: 4
The client's blood pressure should not be measured after the client has exercised, smoked, or in-gested caffeine. The client should wait 30 minutes before assessment of the blood pressure.
The cuff should be deflated at a rate of 2 mm Hg per second. When possible, the client should be sitting in a chair. The blood pressure should be assessed at the same time each day.



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