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; bruit heard in right carotid artery.

Left carotid artery occlusion present; no occlusion of right carotid artery.

Left carotid artery has strong pulse; right carotid artery occluded.

Answer and Explanation

The Correct Answer is B

Choice A rationale
The description of pulse volume (4+ and 0) is not appropriate for documenting a bruit. A bruit is an abnormal sound heard over an artery, indicating turbulent blood flow, not pulse volume.
Choice B rationale
A bruit is an abnormal sound heard over an artery due to turbulent blood flow, often caused by atherosclerosis. The presence of a bruit in the left carotid artery and the absence of sound in the right carotid artery should be documented as such.
Choice C rationale
While a bruit can indicate partial occlusion of an artery, it does not confirm complete occlusion. Complete occlusion would typically result in the absence of blood flow and no sound. Therefore, this choice is incorrect.
Choice D rationale
The presence of a bruit does not necessarily indicate a strong pulse. It indicates turbulent blood flow, which is often due to narrowing or partial blockage of the artery. This choice is incorrect

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice A íationale: Administeíing the píescíibed moíphine sulfate is impoítant foí managing the client’s seveíe pain. Howeveí, the píioíity action is to assess the neuíovasculaí status of the affected limb to ensuíe theíe is no compíomise in ciículation oí neíve function.
Choice B íationale: Píepaíing the cast caít foí immobilization is necessaíy to stabilize the fíactuíe. Howeveí, befoíe immobilization, it is cíucial to peífoím a neuíovasculaí assessment to identify any potential complications that may need immediate attention.
Choice C íationale: Peífoíming a neuíovasculaí assessment of the íight hand is the píioíity action. ľhe client’s capillaíy íefill time is píolonged (4 seconds), indicating potential compíomised ciículation. Assessing the neuíovasculaí status will help deteímine if theíe is an uígent need foí inteívention to píevent fuítheí complications such as compaítment syndíome.
Choice D íationale: Initiating the IV infusion of 0.9% sodium chloíide is impoítant foí maintaining hydíation and ensuíing venous access. Howeveí, the immediate píioíity is to assess the neuíovasculaí status of the affected limb to identify any uígent issues that need to be addíessed.

A. Begin to orient the client to her surroundings in the hospital room. B. Stand directly in front of the client and ask about any hearing loss. C. Obtain a tuning fork to complete Rinne and Weber tuning fork tests. D. Perform a mental status exam to assess the client’s thought processes.

Correct Answer is B

Explanation

Choice A rationale
Orienting the client to her surroundings is important but does not address the immediate issue of potential hearing impairment, which may be causing communication difficulties.
Choice B rationale
Standing directly in front of the client and asking about any hearing loss is the first action to take. The client’s behavior of ignoring questions and speaking loudly to her son suggests a potential hearing impairment. Addressing this issue first can help improve communication and ensure the client understands the nurse’s questions.
Choice C rationale
Obtaining a tuning fork to complete Rinne and Weber tuning fork tests is appropriate for assessing hearing acuity but should be done after initially addressing the potential hearing loss through direct questioning.
Choice D rationale
Performing a mental status exam to assess the client’s thought processes is important but should be done after addressing the potential hearing impairment, which may be the primary cause of the observed behavior.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

While interviewing a newly admitted older female client, the nurse observes that the client ignores Questions asked by the nurse, and speaks loudly to her son who brought her to the hospital. Which action should the nurse implement first?

Correct Answer is B

Explanation

During an abdominal assessment, a client with a temperature of 103°F (39.4°C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement?

While obtaining a client’s health history related to smoking cigarettes, the nurse plans to determine the client’s smoking pack years. What information should the nurse obtain for this calculation? Select all that apply.

To objectively confirm the presence of fever, before taking the client’s temperature, which action should the nurse take?

After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high-pitched almost continuous gurgling in two quadrants. Which action should the nurse implement first?

The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation but reports pain when the pressure is released. Which action should the nurse implement?

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?

An older adult male arrives at the healthcare center with lower abdominal discomfort and frequent urination. The nurse asks the client to provide a urine sample.After an extended period of time, the client returns with only a few drops of urine. Which action should the nurse implement?

During the admission assessment, a client admitted with chest pain reports having no breathing problems and no trouble sleeping at night. To obtain further data regarding possible orthopnea, which action should the nurse take?

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?