What should the nurse do when assessing the carotid arteries of an older patient with cardiovascular disease?
Simultaneously palpate both arteries to compare amplitude.
Instruct the patient to take slow deep breaths during auscultation.
Compress the artery in the upper one-third of the neck while listening with the diaphragm of a stethoscope.
Listen with the bell of the stethoscope to assess for bruits.
The Correct Answer is D
Choice A reason: Simultaneously palpating both carotid arteries is dangerous, risking reduced cerebral blood flow, especially in cardiovascular patients. Using the bell to listen for bruits is safer, so this is incorrect.
Choice B reason: Deep breaths are for lung auscultation, not carotid, where patients hold breath to reduce noise. The bell detects low-pitched bruits, so instructing deep breaths is incorrect for carotid assessment.
Choice C reason: Compressing the carotid artery risks reducing blood flow or dislodging plaques, which is unsafe. Listening with the bell for bruits is the standard method, so this is incorrect.
Choice D reason: Listening with the bell of the stethoscope detects low-frequency bruits, indicating carotid artery narrowing, which is critical in cardiovascular disease. This is the correct technique for safe assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: To calculate the dose, divide the ordered 180 mg by the concentration of 250 mg per 5 ml: (180 mg ÷ 250 mg) × 5 ml = 0.72 × 5 = 3.6 ml. This precise calculation ensures the correct amount of Dilantin is administered, matching the provider’s order.
Choice B reason: A 4.5 ml dose would deliver 225 mg (4.5 ml × 250 mg/5 ml), exceeding the ordered 180 mg. This overdose could increase the risk of toxicity, as Dilantin has a narrow therapeutic range, making this an incorrect choice.
Choice C reason: A 5 ml dose delivers 250 mg (5 ml × 250 mg/5 ml), significantly more than the ordered 180 mg. This excessive dose could lead to adverse effects like ataxia or nystagmus, rendering this choice incorrect for the prescribed amount.
Choice D reason: A 7 ml dose would provide 350 mg (7 ml × 250 mg/5 ml), far exceeding the ordered 180 mg. Such a high dose could cause severe toxicity, including neurological symptoms, making this an inappropriate and unsafe choice.
Correct Answer is D
Explanation
Choice A reason: Superficial tenderness is assessed with light palpation, which evaluates surface sensitivity. Deep palpation probes deeper structures, like organs, and is not primarily for detecting superficial pain, making this an incorrect rationale.
Choice B reason: Bowel motility is assessed via auscultation, which detects bowel sounds, not palpation. Deep palpation evaluates organ size or masses, not dynamic motility, making this an incorrect purpose for the technique.
Choice C reason: The overall impression of skin and superficial musculature is gained through inspection and light palpation. Deep palpation targets deeper structures like organs, not surface characteristics, making this an incorrect rationale.
Choice D reason: Deep palpation is used to assess for enlarged organs, such as hepatomegaly or splenomegaly, by probing deeper abdominal structures. This allows detection of abnormal masses or organ sizes, making this the correct rationale.
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