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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?

A.

Auscultate for any cardiac murmurs

B.

Compare the apical and radial pulse rates

C.

Palpate the quality of the peripheral pulses

D.

Find the point of maximal impulse

E.

Check capillary refill time

Answer and Explanation

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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View Related questions

Correct Answer is C

Explanation

A. The closure of the pulmonic and mitral valves corresponds to heart sound S1, not S2.

B. The tricuspid and mitral valves close with S1.

C. Heart sound S2 represents the closure of the aortic and pulmonic valves, signaling the end of systole and the beginning of diastole.

D. The mitral valve closes with S1, not S2.

E. The pulmonic and tricuspid valves do not correspond with S2.

Correct Answer is C

Explanation

A. Asthma typically presents with wheezing, not fine crackles.

B. Pneumothorax usually presents with decreased or absent breath sounds rather than crackles.

C. Atelectasis, which is common after surgery, can cause fine crackles at the lung bases due to collapsed alveoli reopening during inspiration.

D. Emphysema generally results in diminished breath sounds and hyper-resonance rather than crackles.

E. Bronchitis typically produces coarse crackles or rhonchi, not fine crackles.

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