When assessing a newly admitted client, the nurse notes a thrill along the left sternal border. To obtain more information about the cause of the thrill, which action will the nurse take next?
Auscultate for any cardiac murmurs
Compare the apical and radial pulse rates
Palpate the quality of the peripheral pulses
Find the point of maximal impulse
Check capillary refill time
The Correct Answer is A
A. Auscultate for any cardiac murmurs is correct, as a thrill often indicates turbulent blood flow, which may correlate with murmurs that can be heard upon auscultation.
B. Comparing apical and radial pulse rates is useful in assessing pulse deficits but does not directly address the cause of the thrill.
C. Palpating the quality of the peripheral pulses does not provide specific information about the thrill's origin.
D. Finding the point of maximal impulse is a useful cardiac assessment but does not directly explain the cause of the thrill.
E. Checking capillary refill time assesses peripheral perfusion but does not relate to the thrill's cause.
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Correct Answer is E
Explanation
A. Normal sounds against the sternum would not be low-pitched or soft; they would typically be more pronounced.
B. Bronchovesicular sounds are medium-pitched and are not expected in the lower lobes; they are usually heard in the central area.
C. Bronchial sounds are high-pitched and hollow, typically heard over the trachea, not in the lower lobes.
D. Normal sounds over the trachea would not be described as low-pitched or soft.
E. Vesicular breath sounds are soft, low-pitched, and normal over peripheral lung fields, including the lower lobes, making this the correct interpretation.
Correct Answer is B
Explanation
A. Using the incentive spirometer is primarily aimed at preventing respiratory complications, not directly related to DVT prevention.
B. Dangling the legs off the bed promotes blood flow and prepares the client for ambulation, which helps prevent venous stasis and reduces the risk of DVT.
C. Encouraging ambulation is crucial for DVT prevention, but this task typically requires nursing judgment and assessment.
D. Keeping the knees elevated for prolonged periods may increase the risk of venous stasis, potentially contributing to DVT formation.
E. Limiting fluids without a clinical indication can lead to dehydration, which may increase the risk of blood clots.