Assessing Apical Pulse

Question 1

The apical pulse

Answer 1

is the most reliable noninvasive way to assess cardiac function. The apical pulse rate is the assessment of the number and quality of apical sounds in 1 minute

Question 2

S1 and S2

Answer 2

S1 is the sound of the tricuspid and mitral valves closing at the end of ventricular filling, just before systole begins. S2 is the sound of the pulmonic and aortic valves closing at the end of the systolic contraction.

Question 3

The stethoscope

Answer 3

is a closed cylinder that amplifies sound waves as they reach the surface of the body.

Question 4

The five major parts of the stethoscope are

Answer 4

the earpieces, binaurals, tubing, bell, and diaphragm.

Question 5

Binaurals should be

Answer 5

angled and strong enough so the earpieces stay firmly in place without causing discomfort.

Question 6

The earpieces follow

Answer 6

the contour of the ear canal, pointing toward the face when the stethoscope is in place.

Question 7

longer tubing

Answer 7

decreases sound transmission. Stethoscopes can have one or two tubes

Question 8

The diaphragm

Answer 8

the larger, circular, flat-surfaced portion of the chest piece. It transmits high-pitched sounds created by high-velocity movement of air and blood.

Question 9

The bell

Answer 9

is the cone-shaped portion of the chest piece, usually surrounded by a rubber ring to avoid chilling the patient during placement. It transmits low-pitched sounds created by the low-velocity movement of blood. Hold the bell lightly against the skin for sound amplification.

Question 10

risk factors for alterations in the apical pulse

Answer 10

heart disease, cardiac dysrhythmias, sudden onset of chest pain or acute pain from any site, invasive cardiovascular diagnostic tests, surgery, sudden infusion of a large volume of intravenous (IV) fluid, internal or external hemorrhage, and administration of medications that alter heart function

Question 11

signs and symptoms of altered cardiac function

Answer 11

dyspnea or shortness of breath, fatigue, chest pain, orthopnea, syncope, palpitations, edema of dependent body parts, and cyanosis or pallor of the skin.

Question 12

factors that affect the apical pulse rate and rhythm

Answer 12

age, exercise or activity, athletic conditioning, position changes, medication, temperature, sleep, and sympathetic stimulation.

Question 13

Do not delegate this skill to nursing assistive personnel (NAP) when…

Answer 13

a pulse abnormality is suspected or when the patient’s condition warrants a more accurate assessment.

Question 14

Before delegating routine performance of this skill, be sure to inform NAP of the following:

Answer 14

The frequency of measurement and factors related to the patient’s history, such as the risk for an abnormally slow, rapid, or irregular pulse.
The patient’s usual pulse values and the need to report to you any abnormalities in rate or rhythm.

Question 15

When assessing the apical pulse for the first time…

Answer 15

establish the apical pulse as the baseline. Compare the apical heart rate to the acceptable range for the patient age. Notify the practitioner if it is not within an acceptable range.

Question 16

The PMI of an infant is usually located

Answer 16

at the third to fourth ICS near the left sternal border.
In infants and children younger than 2 years, an apical pulse provides the most reliable HR assessment and is counted for 1 full minute because of possible irregularities in rhythm.
Breath holding in an infant or child affects apical pulse rate.

Question 17

The PMI is often difficult to palpate in some older adults because

Answer 17

the anterior-posterior diameter of the chest increases with age and the heart becomes repositioned because of left ventricular enlargement.

Question 18

When assessing older adult women with sagging breast tissue…

Answer 18

gently lift the breast tissue and place the stethoscope at the fifth ICS or the lower edge of the breast.

Question 19

Heart sounds are sometimes muffled or difficult to hear in older adults because

Answer 19

of an increase in air space in the lungs.

The older adult has a decreased HR at rest.1