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 D

Explanation

A. Fluid restriction by mouth is not typically necessary with opioid administration unless other health conditions require it.
B. A low salt diet is unrelated to opioid administration unless there are concurrent health issues like hypertension or fluid retention.
C. A chest x-ray is not indicated solely due to opioid use.
D. Stool softener medication is commonly prescribed alongside opioid medications because opioids frequently cause constipation due to reduced gastrointestinal motility.
E. Antidiarrheal medication is not needed, as opioids are more likely to cause constipation rather than diarrhea.

A. A client demonstrates how to inject insulin into the abdomen B. A client attends a course on exercise techniques C. A client watches the nurse apply a dressing D. A client lists food choices that are considered part of a healthy diet E. A client nods when told how to take the blood pressure medication

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

Explanation

A. Demonstrating an insulin injection shows hands-on learning and mastery of the skill.
B. Attending a course does not confirm comprehension or skill.
C. Watching a nurse apply a dressing does not guarantee learning; active participation is necessary.
D. Listing healthy food choices indicates understanding of dietary education.
E. Nodding does not confirm learning; it may only indicate acknowledgment.

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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 D

Explanation

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

Explanation

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