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In assessing a client's neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?

Left carotid pulse volume of 4+; right carotid pulse volume of 0.

Left carotid artery bruit present; no bruit heard in right carotid artery.

Left carotid artery has strong pulse; right carotid artery occluded.

Left carotid artery occlusion present; no occlusion of right carotid artery.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Pulse volume and bruit are different assessments; pulse volume is not graded in the context of auscultation findings.

B. A bruit is an abnormal sound heard over an artery, indicating turbulent blood flow, often due to stenosis or narrowing. Documenting a "left carotid artery bruit present" accurately reflects the findings.

C. The presence of a bruit does not necessarily mean the pulse is strong or that there is occlusion.

D. A bruit indicates turbulent flow, not necessarily complete occlusion.

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A. Palpate the client's muscle tone. B. Instruct the client to close his eyes. C. Apply resistance to the client's arms. D. Give the client an object to hold.

Correct Answer is C

Explanation

Rationale:

A. Palpating muscle tone is important but should be done in conjunction with resistance testing to assess strength.

B. Asking the client to close his eyes is not necessary for assessing muscle strength.

C. Applying resistance while the client extends and flexes his arms helps evaluate the muscle strength and function accurately.

D. Providing an object to hold is not relevant for assessing muscle strength in this context.

A. Apply light pressure proximal to the IV site. B. Assess the radial pulse distal to the IV site. C. Assist the client to straighten the right arm. D. Elevate the client's right arm on one pillow.

Correct Answer is C

Explanation

Rationale:

A. Applying pressure proximal to the IV site is not appropriate and could cause further complications.

B. Assessing the radial pulse is important but is not the immediate response to the occlusion alarm.

C. Straightening the arm can help relieve a positional occlusion, which is a common cause of such alarms.

D. Elevating the arm may help with venous return but is not a first-line action for addressing the occlusion alarm.

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In assessing a client's neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?

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Correct Answer is C

Explanation

Correct Answer is C

Explanation

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Take full exam for free In assessing a client's neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?

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In assessing a client's neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?