The nurse is teaching a nursing student the correct technique for assessing an apical pulse. Which method when used by the student demonstrates she knows the correct location to take an adult patient's apical pulse?
a. Percusses the left ventricular wall
b. Palpates along the left sternal border
c. Directs the patient to lie in a supine posi-tion
d. Listens at the fifth intercostal space at the point of maximal impulse (PMI)
D
To locate the apical pulse, the nurse locates the fifth intercostal space on the left midclavicular line; this point should coincide with the patient's PMI. Evaluation of the heart rarely includes percussion. Palpation along the left sternal border reveals cardiac thrusts and thrills; however, the apical pulse is not proximate to the sternal border. The nurse positions the patient with the head of the bed at 30 degrees for patient comfort and to facilitate cardiac assessment.
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