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","D"]

Explanation

A. Asking about shortness of breath is critical subjective data that indicates respiratory distress.
B. Palpating for masses is more of a physical assessment and does not yield subjective data.
C. Inspecting skin and nails is also part of the objective assessment rather than subjective data.
D. Inquiring about the color and quantity of sputum provides important subjective data related to respiratory function.
E. Auscultation is an objective assessment technique and does not pertain to subjective data.

A. Asthma B. Pneumothorax C. Atelectasis D. Emphysema E. Bronchitis

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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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

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Correct Answer is ["A","D"]

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