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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Correct Answer is D

Explanation

A. When bronchial breath sounds are auscultated in the trachea.

Auscultating bronchial breath sounds in the trachea is a normal finding, as the trachea is close to the upper airway, and this is where bronchial sounds are normally heard. However, if these sounds are heard in the peripheral lung fields, it can indicate an abnormal condition.

B. When the client is experiencing excessive sneezing from a tree pollen allergy.

Excessive sneezing due to allergies would not typically result in increased breath sounds. Allergies may cause nasal congestion, but they don't directly lead to increased breath sounds.

C. When the client is resting in bed and not experiencing respiratory issues.

If a client is at rest and not experiencing any respiratory issues, breath sounds should typically be normal. There would be no reason to expect increased breath sounds in this scenario.

D. When the bronchial tree is obstructed by secretions.

Increased breath sounds, such as wheezing or rhonchi, can be auscultated when there is an obstruction in the bronchial tree due to secretions, narrowing of the airways, or other causes. These sounds are typically abnormal and indicate an issue with air movement through the airways.

A. Clear and equal breath sounds bilaterally B. Oxygen saturation of 98% on room air C. Cough producing clear, thin sputum D. Visible use of accessory muscles during inhalation

Correct Answer is D

Explanation

A. Clear and equal breath sounds bilaterally

Explanation: Clear and equal breath sounds bilaterally indicate normal lung sounds, suggesting proper air exchange in both lungs. This is a normal finding and does not require immediate reporting.

B. Oxygen saturation of 98% on room air

Explanation: An oxygen saturation level of 98% on room air indicates adequate oxygenation of the blood. This is a normal and healthy oxygen saturation level and does not require immediate reporting.

C. Cough producing clear, thin sputum

Explanation: A cough producing clear, thin sputum is indicative of a non-infected or non-inflammatory condition in the respiratory system. Clear and thin sputum is often normal, especially in the absence of other symptoms. It does not require immediate reporting unless the client has other concerning symptoms.

D. Visible use of accessory muscles during inhalation

Explanation: Visible use of accessory muscles, such as neck or intercostal muscles, during inhalation suggests that the client is working hard to breathe. This could indicate respiratory distress, potentially due to conditions like asthma, COPD (Chronic Obstructive Pulmonary Disease), or other severe lung problems. It's a concerning sign and should be reported to the healthcare practitioner promptly for further evaluation and intervention.

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

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Naxlex Comprehensive Predictor Exams

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Explanation

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