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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale:

Apply the skin sealant on damp skin. Rationale: Applying skin sealant on damp skin is not the recommended approach for securing an ostomy appliance. It's important to ensure that the skin is clean and dry before applying the sealant or the skin barrier. Moisture can compromise adhesion and lead to skin irritation or appliance detachment.

Choice B rationale:

Remove the appliance before emptying the pouch. Rationale: Removing the appliance before emptying the pouch is not a necessary step when changing an ostomy appliance. Typically, the pouch can be emptied without removing the entire appliance, which helps maintain the seal and reduces unnecessary skin exposure.

Choice C rationale:

Ensure that the skin is slightly damp for better adhesion of the pouch. Rationale: Ensuring that the skin is slightly damp is not advisable for better adhesion of the pouch. The skin should be completely dry before applying the pouch to ensure proper adhesion. Moisture on the skin can lead to leakage or detachment of the appliance.

Choice D rationale:

Trace the size of stoma onto the skin barrier. Rationale: This choice is the correct answer because tracing the size of the stoma onto the skin barrier ensures a precise fit, which is crucial for preventing leaks and maintaining the integrity of the ostomy. A proper fit also helps in preventing skin irritation and discomfort. Choosing the correct barrier size based on the stoma's dimensions is a key aspect of effective ostomy care.

A. When administering an enema, the nurse inserts the tip of the enema tube 8 cm (3.1 in). B. When caring for a client's body after death, the nurse elevates the head of the bed. C. When providing indwelling catheter care, the nurse uses a clean washcloth, soap, and water. D. When removing a peripheral IV catheter, the nurse uses scissors to remove the tape that secures the catheter.

Correct Answer is D

Explanation

The correct answer is choice d. When removing a peripheral IV catheter, the nurse uses scissors to remove the tape that secures the catheter.

Choice A rationale:

Inserting the tip of the enema tube 8 cm (3.1 in) is within the recommended range for adults, which is typically 7.5 to 10 cm (3 to 4 in). This action does not require intervention.

Choice B rationale:

Elevating the head of the bed when caring for a client’s body after death is a standard practice to prevent discoloration of the face and to facilitate drainage. This action does not require intervention.

Choice C rationale:

Using a clean washcloth, soap, and water for indwelling catheter care is appropriate and follows infection control guidelines. This action does not require intervention.

Choice D rationale:

Using scissors to remove the tape that secures a peripheral IV catheter is unsafe as it poses a risk of cutting the catheter or the client’s skin. This action requires intervention to ensure the nurse uses a safer method, such as using adhesive remover or gently peeling the tape away by hand.

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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?

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