The nurse is assessing the client's cardiovascular system. Which techniques are appropriate for the nurse to use during this assessment? Select all that apply
1. Continuing the exam when the client complains of discomfort when lying flat.
2. Auscultating the apical impulse at the fifth intercostal space at the midclavicular line.
3. Examining the client's legs and noting that the client's hair is evenly distributed.
4. Palpating the client's carotid arteries simultaneously to determine pulse strength, rhythm, and rate.
5. Examining the client's hands and fingers and noting the presence of clubbing.
Correct Answer: 2, 3, 5
If the student nurse has determined the apical impulse to be located at the fifth intercostal space at the midclavicular line, this is normal. Examining the client's legs and noting that the client's hair is evenly distributed is an appropriate part of the examination. Patchy hair distribution can indicate that there is a circulatory problem. It is appropriate to examine the client's hands and fingers to determine the existence of peripheral circulatory problems. If the client complains of any discomfort during the examination, the nurse should pause the examination and the client should be assisted into a more comfortable position for the rest of the examination. Not all clients will be able to assume every position associated with this examination. The carotid pulses must never be palpated simultaneously since this may obstruct blood flow to the brain, resulting in severe bradycardia or asystole.
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