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 D
Explanation
Choice A rationale
Checking distal phalanges capillary refill assesses circulation but does not specifically identify findings consistent with paresthesia.
Choice B rationale
Evaluating the client’s muscle strength and hand grips assesses motor function but not sensory changes associated with paresthesia.
Choice C rationale
Reviewing the client’s serum electrolytes can provide information about potential causes of paresthesia but does not directly identify sensory findings.
Choice D rationale
Observing the skin for erythema, edema, and warmth can help identify additional findings consistent with paresthesia, such as inflammation or nerve irritation.
Correct Answer is D
Explanation
Choice A rationale
Giving the client 8 ounces (236.5 mL) of water to drink may help in obtaining a urine sample, but it does not address the immediate concern of potential bladder distention.
Choice B rationale
Sending the sample for laboratory evaluation is not appropriate when the sample is insufficient. The nurse should first address the underlying issue of why the client could not provide an adequate sample.
Choice C rationale
Instructing the client to attempt to urinate again may not be effective if the client is experiencing bladder distention or another underlying issue preventing urination.
Choice D rationale
Evaluating the client for bladder distention is the most appropriate action. Bladder distention can cause lower abdominal discomfort and difficulty urinating. Assessing for distention can help determine if the client needs further intervention, such as catheterization.