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 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.
Correct Answer is A
Explanation
A. In peripheral arterial insufficiency, blood flow is reduced, leading to cooler skin temperatures, especially in the affected extremity.
B. Nail appearance may be unhealthy due to poor perfusion; nails may become thickened or grow slowly.
C. Skin is typically cool and may be dry, not warm, indicating reduced blood flow.
D. A pulse of 2+ is within normal range; however, pulses may be diminished or absent in cases of significant arterial insufficiency.
E. The leg typically does not appear swollen; rather, it may show signs of atrophy or hair loss due to inadequate blood supply.