The student nurse is assessing the client's cardiovascular system while the experienced nurse observes
The employment of which of the following techniques by the student nurse indicate the need for further education? Standard Text: Select all that apply. 1. The client complains of discomfort while lying flat. The student nurse auscultates the client's chest quickly while the client continues to lie flat.
2. The student nurse determines that the apical impulse is located at the fifth intercostal space at the midclavicular line.
3. The student nurse examines the client's legs and notes that the client's hair is evenly distributed.
4. The student nurse gently palpates the client's carotid arteries simultaneously to determine pulse strength, rhythm, and rate.
5. The student nurse examines the client's hands and fingers and notes the presence of clubbing.
1,4
Rationale 1: The client complains of discomfort while lying flat. The student nurse auscultates the client's chest quickly while the client continues to lie flat. 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.
Rationale 2: The student nurse determines that the apical impulse is located at the fifth intercostal space at the midclavicular line. This is normally where the point of maximal impulse can be palpated.
Rationale 3: The student nurse examines the client's legs and notes that the client's hair is evenly distributed. This is an appropriate part of the examination. Patchy hair distribution can indicate that there is a circulatory problem.
Rationale 4: The student nurse gently palpates the client's carotid arteries simultaneously to determine pulse strength, rhythm, and rate. The carotid pulses must never be palpated simultaneously since this may obstruct blood flow to the brain, resulting in severe bradycardia or asystole.
Rationale 5: The student nurse examines the client's hands and fingers and notes the presence of clubbing. It is appropriate to examine the client's hands and fingers to determine the existence of peripheral circulatory problems.
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