While auscultating a client’s abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding?
A minor variation.
Normal borborygmus sounds.
Possible renal artery stenosis.
Hyperactive bowel sounds.
The Correct Answer is C
Choice A rationale
A minor variation may refer to a benign finding or a slight deviation from the norm. However, a low-pitched blowing sound in the upper midline area would not typically be considered a minor variation and may warrant further investigation.
Choice B rationale
Borborygmi are normal bowel sounds characterized by gurgling, rumbling, or growling noises produced by the movement of gas and fluid in the intestines. However, a low-pitched blowing sound in the upper midline area would not typically be described as normal borborygmi.
Choice C rationale
A low-pitched blowing sound in the upper midline area could indicate a renal artery bruit, which is a sign of renal artery stenosis. Renal artery stenosis is a narrowing of the renal artery, often due to atherosclerosis, which can lead to decreased blood flow to the kidneys. A renal artery bruit may be auscultated over the renal arteries and is indicative of turbulent blood flow through the narrowed artery.
Choice D rationale
Hyperactive bowel sounds are typically characterized by loud, high-pitched gurgles heard throughout the abdomen. They are often associated with increased intestinal motility, such as in gastroenteritis or diarrhea, rather than a low-pitched blowing sound in the upper midline area.
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Correct Answer is C
Explanation
Choice A rationale: Administering the prescribed morphine sulfate is important for managing the client’s severe pain. However, the priority action is to assess the neurovascular status of the affected limb to ensure there is no compromise
in circulation or nerve function.
Choice B rationale: Preparing the cast cart for immobilization is necessary to stabilize the fracture. However, before immobilization, it is crucial to perform a neurovascular assessment to identify any potential complications that may need
immediate attention.
Choice C rationale: Performing a neurovascular assessment of the right hand is the priority action. The client’s capillary refill time is prolonged (4 seconds), indicating potential compromised circulation. Assessing the neurovascular status will help determine if there is an urgent need for intervention to prevent further complications such as compartment
syndrome.
Choice D rationale: Initiating the IV infusion of 0.9% sodium chloride is important for maintaining hydration and ensuring venous access. However, the immediate priority is to assess the neurovascular status of the affected limb to identify any urgent issues that need to be addressed.
Correct Answer is C
Explanation
Choice A rationale
Restricting activity to bed rest is important but not the most immediate intervention for a client with a high fever and pain during deep palpation.
Choice B rationale
Monitoring urinary output is important but not the most immediate intervention in this scenario.
Choice C rationale
Initiating NPO (nothing by mouth) status is crucial to prepare the client for potential surgical intervention, especially if the pain suggests an acute abdominal condition.
Choice D rationale
Obtaining an electrocardiogram is important but not the most immediate intervention for a client with abdominal pain and high fever.