Nokea
During a shift assessment, the nurse is identifying the clients point of maximum impulse (PMI). Where will the nurse best palpate the PMI?
- A. Left midclavicular line of the chest at the level of the nipple
- B. Left midclavicular line of the chest at the fifth intercostal space
- C. Midline between the xiphoid process and the left nipple
- D. Two to three centimeters to the left of the sternum
Correct Answer: B
Rationale: The left ventricle is responsible for the apical beat or the point of maximum impulse, which is normally palpated in the left midclavicular line of the chest wall at the fifth intercostal space.
You may also like to solve these questions
The nurse is caring for a patient who is undergoing an exercise stress test. Prior to reaching the target heart rate, the patient develops chest pain. What is the nurses most appropriate response?
- A. Administer sublingual nitroglycerin to allow the patient to finish the test
- B. Initiate cardiopulmonary resuscitation
- C. Administer analgesia and slow the test
- D. Stop the test and monitor the patient closely
Correct Answer: D
Rationale: Signs of myocardial ischemia would necessitate stopping the test. CPR would only be necessary if signs of cardiac or respiratory arrest were evident.
The cardiac care nurse is reviewing the conduction system of the heart. The nurse is aware that electrical conduction of the heart usually originates in the SA node and then proceeds in what sequence?
- A. SA node to bundle of His to AV node to Purkinje fibers
- B. SA node to AV node to Purkinje fibers to bundle of His
- C. SA node to bundle of His to Purkinje fibers to AV node
- D. SA node to AV node to bundle of His to Purkinje fibers
Correct Answer: D
Rationale: The normal electrophysiological conduction route is SA node to AV node to bundle of His to Purkinje fibers.
A critical care nurse is caring for a patient with a pulmonary artery catheter in place. What does this catheter measure that is particularly important in critically ill patients?
- A. Pulmonary artery systolic pressure
- B. Right ventricular afterload
- C. Pulmonary artery pressure
- D. Left ventricular preload
Correct Answer: D
Rationale: Monitoring of the pulmonary artery diastolic and pulmonary artery wedge pressures is particularly important in critically ill patients because it is used to evaluate left ventricular filling pressures (i.e., left ventricular preload). This device does not directly measure the other listed aspects of cardiac function.
The nurse is caring for a patient admitted with angina who is scheduled for cardiac catheterization. The patient is anxious and asks the reason for this test. What is the best response?
- A. Cardiac catheterization is usually done to assess how blocked or open a patients coronary arteries are
- B. Cardiac catheterization is most commonly done to detect how efficiently a patients heart muscle contracts
- C. Cardiac catheterization is usually done to evaluate cardiovascular response to stress
- D. Cardiac catheterization is most commonly done to evaluate cardiac electrical activity
Correct Answer: A
Rationale: Cardiac catheterization is usually used to assess coronary artery patency to determine if revascularization procedures are necessary. A thallium stress test shows myocardial ischemia after stress. An ECG shows the electrical activity of the heart.
A patients declining cardiac status has been attributed to decreased cardiac action potential. Interventions will be aimed at restoring what aspect of cardiac physiology?
- A. The cycle of depolarization and repolarization
- B. The time it takes from the firing of the SA node to the contraction of the ventricles
- C. The time between the contraction of the atria and the contraction of the ventricles
- D. The cycle of the firing of the AV node and the contraction of the myocardium
Correct Answer: A
Rationale: This exchange of ions creates a positively charged intracellular space and a negatively charged extracellular space that characterizes the period known as depolarization. Once depolarization is complete, the exchange of ions reverts to its resting state; this period is known as repolarization. The repeated cycle of depolarization and repolarization is called the cardiac action potential.