When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location?

Correct Answer: A

Rationale: The correct answer is A, between the scapulae. Tactile fremitus is most intense over areas where there is a solid lung structure close to the chest wall, such as between the scapulae where the main bronchi are located. This proximity allows for better transmission of vibrations generated by vocalization. Choices B, C, and D are incorrect because they do not align with the anatomical locations of solid lung structures. The third intercostal space, midaxillary line, and lower lobes do not provide the necessary proximity to produce intense tactile fremitus.

Correct Answer: C

Rationale: The correct answer is C: "Where did the rash first appear—on the nipple, the areola, or the surrounding skin?" This question is crucial because the location of the rash can provide valuable clues about the potential cause. For example, a rash on the nipple may point towards issues like Paget's disease, while a rash on the areola could suggest eczema or contact dermatitis. On the other hand, a rash on the surrounding skin may indicate a fungal infection or allergic reaction. By identifying the precise location of the rash, the nurse can narrow down the differential diagnosis and develop an appropriate care plan. Summary: A: "Is the rash raised and red?" - This question focuses on the appearance of the rash but does not provide specific information about its location, which is more critical in determining the cause. B: "Does it appear to be cyclic?" - This question is not as directly relevant to identifying the cause of the rash compared to pinpointing its location. D

Correct Answer: C

Rationale: The correct sequence of the electrical stimulus in the cardiac cycle is SA node → AV node → bundle of His → bundle branches. The rationale is as follows: 1. The SA node initiates the electrical impulse in the heart. 2. The impulse travels to the AV node, which serves as a delay mechanism to ensure proper coordination of atrial and ventricular contractions. 3. From the AV node, the impulse then travels to the bundle of His, which conducts the impulse to the bundle branches. 4. Finally, the impulse is transmitted through the bundle branches to the Purkinje fibers, which then distribute the impulse throughout the ventricles for coordinated contraction. Therefore, choice C is correct as it accurately represents the sequential pathway of the electrical stimulus in the cardiac cycle. Choices A, B, and D are incorrect as they do not follow the physiologically accurate sequence of the cardiac conduction system.

Correct Answer: C

Rationale: The dull sound over the liver during percussion indicates a normal finding. The liver is a solid organ, so it produces a dull sound. Air-filled organs would produce a tympanic sound. Presence of fluid would produce a shifting dullness. Presence of a tumor may not necessarily affect the percussion sound. Therefore, the dull sound over the liver is a normal finding during abdominal percussion, indicating option C is the correct answer.

Correct Answer: D

Rationale: Answer D is correct because the first step in managing an undescended testicle is to attempt to bring it down from the inguinal canal. This is important to prevent complications and improve fertility. Referring to urology (choice A) may be necessary if the testicle cannot be brought down. Rechecking in 6 months (choice B) delays necessary intervention. Telling the parent the testicle is absent (choice C) is incorrect as it may cause unnecessary worry, and the testicle could still be present in the canal.