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. Elevating the head of the bed is important for swallowing and preventing aspiration but is secondary to ensuring correct patient identification.
B. Using at least two different methods to identify the client is the most important step to prevent medication errors. This ensures that the correct medication is given to the correct patient.
C. Providing water is helpful but not as critical as ensuring the correct patient is identified.
D. Rechecking the medications against the MAR is important but should be done in conjunction with proper patient identification.
Correct Answer is D
Explanation
Rationale:
A. The clavicle is an important landmark but not the ideal starting point for auscultating breath sounds.
B. The sternum is also not the correct starting location for breath sound auscultation.
C. The aortic site is unrelated to lung auscultation.
D. The lung apex, located above the clavicle, is the correct location to begin auscultating anterior breath sounds. This systematic approach ensures all areas of the lungs are assessed for normal and abnormal breath sounds.