A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. the nurse auscultates a high-pitched scratching sound during both systole and diastole with diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? Pericardial friction rub A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? Place the bladder of the cuff over the posterior aspect of the thigh A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR? Confirm unresponsiveness A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first? Identify the client using two identifiers A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? Administer analgesics to the child on a routine schedule throughout the day and night. A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits? The involvement of the client in planning the chang