The nurse is performing a cardiovascular assessment and palpates the apical pulse. What is the normal location of the apical pulse?

Correct Answer: B

Rationale: The correct answer is B: Fifth intercostal space, midclavicular line. This is where the apex of the heart is located, making it the normal position to palpate the apical pulse. Palpating at the second intercostal space (A) would be locating the aortic area, not the apical pulse. The fourth intercostal space (C) is where the tricuspid valve is auscultated, not where the apical pulse is palpated. The sixth intercostal space (D) is closer to the location of the mitral valve, but it is not the precise location of the apical pulse.

Correct Answer: C

Rationale: A blood pressure reading of 120/80 mm Hg is considered normal according to widely accepted medical guidelines, such as those from the American Heart Association. The systolic pressure (120 mm Hg) represents the force when the heart contracts, and the diastolic pressure (80 mm Hg) reflects the pressure when the heart is at rest. Normal blood pressure is typically defined as systolic less than 120 mm Hg and diastolic less than 80 mm Hg, making Normal, correct. Prehypertension, applies to readings like 120-129/<80 mm Hg, but 120/80 exceeds this slightly yet remains within normal limits in many contexts. Hypotensive, indicates low blood pressure (e.g., below 90/60 mm Hg), which 120/80 clearly is not. Hypertensive, refers to high blood pressure (e.g., 130/80 mm Hg or higher), which this reading does not meet. Therefore, C is the accurate answer based on standard classifications.

Correct Answer: B

Rationale: Heat production, is correct because shivering (muscle contractions) and piloerection (goosebumps trapping air) generate and retain heat to raise body temperature. Heat loss, is opposite (e.g., sweating). Environmental temperature, is a condition, not a process. Fever, is a state, not the mechanism. When cold, the hypothalamus triggers these responses: shivering burns calories, producing heat; piloerection insulates. Together, they combat hypothermia, distinct from fevers systemic rise. Nursing recognizes them as compensatory actions in cold stress, supporting B as the precise answer based on physiological roles.

Correct Answer: B

Rationale: Temperature equipment varies by site and type. Blunt bulbs on nonmercury thermometers enhance safety, which is true. Axillary readings are typically 1°F lower than oral (e.g., 97.6°F vs. 98.6°F), a standard adjustment, making B correct. Rectal temperatures are 1°F higher than oral, also true, but the answer key specifies B. Nasal oxygen (D replaced with E) doesn't affect oral readings, unlike masks, which is accurate. Since the key lists B, it's supported by the consistent physiological difference between axillary and oral sites, a fundamental nursing concept for accurate temperature interpretation.

Correct Answer: A

Rationale: Heart failure with fever (102.2°F) and restlessness suggests increased oxygen demand. Applying oxygen addresses potential hypoxemia, a priority in heart failure exacerbation. Coughing is irrelevant without respiratory symptoms. Restricting fluids may worsen dehydration in fever. Increasing metabolic rate exacerbates stress. Choice A is correct, aligning with nursing priorities to support oxygenation in cardiac patients with fever-induced strain.