A nurse notes that a child's chart describes a heave. Which assessment should the nurse perform to correlate with this finding?
A.
Assess for nausea.
B.
Auscultate for heart sounds.
C.
Listen to lung sounds.
D.
Review the last ECG
ANS: B
A heave is an abnormal tremor that accompanies a vascular or cardiac murmur, so the nurse would listen to heart sounds. Lung sounds and ECGs are not directly related to a heave. Nausea is not related at all.
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