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 D
Explanation
Choice A rationale
Fissuring refers to deep cracks or splits in the skin. While it can occur in various skin conditions, it is not a typical manifestation of an allergic reaction to an insect bite.
Choice B rationale
Excoriation refers to a scratch or abrasion on the surface of the skin, often resulting from scratching due to itching. While this can occur secondary to an allergic reaction, it is not a primary characteristic of such reactions.
Choice C rationale
Papules are small, raised, solid bumps on the skin that are typically less than 1 centimeter in diameter. They can be a result of various skin conditions, but they are not specifically associated with allergic reactions to insect bites.
Choice D rationale
Wheals, also known as hives or urticaria, are raised, red or skin-colored welts on the skin that often itch and can appear rapidly in response to an allergen such as an insect bite. They are a characteristic feature of allergic reactions and are caused by the release of histamine.