A nurse is auscultating a client's carotid artery while performing a focused cardiac assessment and hears a bruit. The nurse should identify this finding as a manifestation of which of the following conditions?
Dysrhythmia.
Cardiac murmur.
Hypotension.
Narrowed arterial lumen.
The Correct Answer is D
Choice A rationale:
Dysrhythmia refers to irregular heart rhythms and is not associated with the carotid artery. It involves issues with the heart's electrical conduction system.
Choice B rationale:
A cardiac murmur is an abnormal sound heard during the heartbeat cycle, usually indicating turbulent blood flow across heart valves. It's not directly related to the carotid artery.
Choice C rationale:
Hypotension refers to low blood pressure, which might impact blood flow through the carotid artery but wouldn't directly cause the sound known as a bruit.
Choice D rationale:
A bruit heard while auscultating the carotid artery suggests a narrowed arterial lumen. A bruit is a whooshing or blowing sound caused by turbulent blood flow due to arterial narrowing or blockage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Selecting an injection site on the abdomen 5 cm (2 in) from the umbilicus might be an appropriate instruction for some subcutaneous injections, but the specific injection site can vary based on the medication and client's needs. This choice is not a universal instruction for all subcutaneous injections.
Choice B rationale:
Expelling the air bubble from a prefilled syringe before injecting the medication is essential to ensure accurate dosing. Air bubbles can displace medication and lead to underdosing. This step is crucial for safe and effective administration.
Choice C rationale:
Aspirating prior to injecting medication is a technique used for intramuscular injections to ensure the needle is not in a blood vessel. However, for subcutaneous injections, aspirating is not necessary or recommended, as it can cause tissue damage and discomfort.
Choice D rationale:
Inserting the needle at a 15° angle is not a standard practice for subcutaneous injections. Subcutaneous injections are typically administered at a 45° or 90° angle, depending on the needle length and client's body composition. A 15° angle would not ensure proper medication delivery.
Correct Answer is D
Explanation
Choice A rationale: Administering a rectal suppository is a medication administration task that should be performed by a licensed nurse, not delegated to an assistive personnel.
Choice B rationale: Instructing a client to use an incentive spirometer involves providing education and ensuring proper technique, which falls within the scope of practice of a licensed nurse.
Choice C rationale: Measuring blood glucose for a client with diabetic ketoacidosis involves monitoring a critical condition and interpreting results, which should be done by a licensed nurse.
Choice D rationale: Using a pulse oximeter to measure oxygen saturation is a simple and routine task that can be delegated to an assistive personnel for a stable client who is ready for discharge.
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