The nurse is assessing the carotid arteries of a client with cardiovascular disease. What action should be performed next by the nurse?

Discuss that a light will be directed at the neck to observe for pulsations of the artery

instruct the client to take a deep breath and "hold" while the nurse briefly auscultates

Demonstrate that both arteries will be palpated simultaneously to compare amplitude

Show the client the diaphragm of the stethoscope that will be placed on the neck

Answer and Explanation

The Correct Answer is C

A. Discuss that a light will be directed at the neck to observe for pulsations of the artery:

This choice is incorrect. Directing light at the neck is not a standard method for assessing carotid artery pulsations. The carotid artery is usually assessed by palpation to feel the pulse rather than visual observation.

B. Instruct the client to take a deep breath and "hold" while the nurse briefly auscultates:

This choice is incorrect. Auscultation is typically not used to assess carotid artery pulsations. Palpation (feeling the pulse) is the primary method used for this assessment.

C. Demonstrate that both arteries will be palpated simultaneously to compare amplitude:

This choice is correct. Palpating both carotid arteries simultaneously allows the nurse to compare the amplitude (strength) of the pulses. This comparison helps in assessing the symmetry of the pulses and ensures there are no significant differences between the two sides, which could indicate vascular abnormalities.

D. Show the client the diaphragm of the stethoscope that will be placed on the neck:

This choice is incorrect. The diaphragm of the stethoscope is not typically used for palpating pulses. Palpation involves using the fingertips to feel the pulse and assess its strength and regularity.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Consists of two lobes.

This statement is correct. The left lung consists of two lobes: the upper lobe and the lower lobe. The right lung, not the left lung, has three lobes: upper, middle, and lower lobes.

B. Primarily consists of an upper lobe on the posterior chest.

This statement is not accurate. The upper lobe of the left lung is present in the anterior and posterior parts of the chest. It is not limited to the posterior chest.

C. Is shorter than the right lung because of the underlying stomach.

This statement is not correct. The left lung is not shorter due to the underlying stomach. The left lung is slightly smaller than the right lung to accommodate the space for the heart, but this size difference is not due to the stomach.

D. Is divided by the horizontal fissure.

This statement is not accurate. The left lung is not divided by the horizontal fissure. The horizontal fissure is a feature of the right lung, not the left lung. The left lung is divided by the oblique fissure into the upper and lower lobes

A. Checks the instrument gauge to ensure the reading starts at zero B. Centers the cuff bladder over the client's brachial artery C. Places the client's arm above the level of the client's heart D. Wraps the blood pressure cuff around the client's arm using firm pressure

Correct Answer is C

Explanation

A. Checks the instrument gauge to ensure the reading starts at zero:

This action is correct. Before taking a blood pressure reading, it's essential to ensure that the instrument's gauge starts at zero. This ensures accurate measurement as the reading reflects the pressure above zero.

B. Centers the cuff bladder over the client's brachial artery:

This action is correct. Proper placement of the blood pressure cuff over the brachial artery is crucial for accurate readings. Centering the cuff ensures that the artery is correctly compressed for measurement.

C. Places the client's arm above the level of the client's heart:

This action is incorrect. Placing the arm above heart level can result in a falsely low blood pressure reading. The arm should be at the same level as the heart to obtain an accurate measurement.

D. Wraps the blood pressure cuff around the client's arm using firm pressure:

This action is correct, but it's important to note that while the cuff should be snug, it should not be too tight or too loose. Wrapping the cuff with firm, even pressure ensures proper compression of the artery for an accurate measurement.

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