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

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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Correct Answer is A,E,D,F,C,B

Explanation

Unoxygenated blood flows from the body into the right atrium, then passes through the pulmonary artery to the lungs. After receiving oxygen in the lungs, blood flows back to the heart via the pulmonary vein into the left atrium. It then moves into the left ventricle and is finally pumped out to the body through the aorta.

A. Performing chest percussion on a client with atelectasis B. Auscultate lungs on a client with audible wheezing C. Taking vital signs on a male client with severe dyspnea D. Suctioning a client with hemoptysis (bloody sputum) E. Setting up a meal tray for a client with COPD

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A,E,D,F,C,B

Explanation

The RN and certified nursing assistant/patient care assistance (CNA/PCA) are caring for five clients on a medical/surgical unit. Which of the following tasks would be most appropriate for the nurse to delegate to the CNA/PCA?

Correct Answer is E

Explanation

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