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. Chest percussion is a specialized skill that should be performed by a nurse or respiratory therapist due to the risk of complications.
B. Lung auscultation requires assessment skills and clinical judgment, which is within the RN’s scope of practice, not the CNA’s.
C. Taking vital signs on a client with severe dyspnea may require immediate interpretation and intervention, best handled by an RN.
D. Suctioning requires skill and knowledge of the procedure and potential complications, which should be performed by the RN.
E. Setting up a meal tray is an appropriate task for a CNA, as it does not require nursing judgment and supports the client’s nutritional needs.
Correct Answer is E
Explanation
A. In asthma, increased airway resistance can lead to decreased fremitus due to air trapping and poor conduction of vibrations.
B. Emphysema results in hyperinflated lungs, which typically decreases tactile fremitus because of increased air in the alveoli.
C. Pneumothorax involves air in the pleural space, leading to decreased tactile fremitus as well, since air does not conduct vibrations well.
D. Acute bronchitis can cause some changes in fremitus, but it typically does not significantly increase it.
E. Pneumonia causes consolidation of lung tissue, which increases tactile fremitus due to enhanced transmission of vibrations through solidified lung tissue.