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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. Use a pulse oximeter to assess oxygen saturation. B. Advise the client to reduce the medication dose. C. Report the finding to the healthcare provider. D. Check the client's capillary glucose level.

Correct Answer is C

Explanation

Rationale:

A. Jaundice is not related to oxygen saturation, so using a pulse oximeter is not appropriate in this situation.

B. Reducing the dose of acetaminophen may be necessary, but this decision should be made after evaluating liver function.

C. Jaundice, characterized by yellowing of the skin, can indicate liver dysfunction, possibly due to acetaminophen overuse or toxicity. The nurse should report this finding to the healthcare provider immediately for further evaluation and management.

D. Checking capillary glucose levels is not relevant to the assessment of jaundice.

A. Remove the drainage bag and apply antibiotic ointment around the stoma. B. Apply a pulse oximeter to determine the client's oxygen saturation level. C. Replace the colostomy supplies with non-latex hypoallergenic supplies. D. Notify the healthcare provider of the appearance of the stoma immediately.

Correct Answer is D

Explanation

Rationale:

A. Applying antibiotic ointment is not appropriate for this situation as the issue is likely compromised blood flow, not infection.

B. Checking oxygen saturation is not related to the color change of the stoma.

C. Switching to non-latex supplies is important for clients with latex allergies but is not relevant to the immediate problem.

D. A dark red to bluish color of the stoma suggests compromised blood flow and possible ischemia, which requires immediate medical attention. The nurse should notify the healthcare provider immediately to address this potentially serious complication.

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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 D

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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While assessing a client who takes acetaminophen for chronic pain, the nurse observes that the client's skin looks yellow in color. Which action should the nurse take in response to this finding?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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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?