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.
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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Correct Answer is B
Explanation
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.
Correct Answer is A
Explanation
Rationale:
A. Administering insulin per sliding scale is appropriate for managing elevated blood glucose in a patient who is NPO and cannot take oral hypoglycemics like metformin.
B. Repeating the test in one hour delays necessary treatment and does not address the current hyperglycemia.
C. A continuous IV infusion of insulin is more appropriate for severe hyperglycemia or critical care situations, but obtaining a sliding scale prescription is more routine in this context.
D. Administering metformin with a sip of water could be considered if the provider orders it, but typically, oral hypoglycemics are held when a patient is NPO.