After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound.
Which action should the nurse take next?
Continue with the blood pressure assessment.
Reposition the stethoscope over the brachial artery.
Reinflate the cuff to a higher number.
Note the presence of an auscultatory gap.
The Correct Answer is D
Choice A rationale:
Continue with the blood pressure assessment. Continuing with the blood pressure assessment without addressing the observed auscultatory gap could lead to an inaccurate reading. It's important to investigate and note the presence of an auscultatory gap before proceeding with the assessment.
Choice B rationale:
Reposition the stethoscope over the brachial artery. Repositioning the stethoscope may not resolve the issue of hearing silence followed by a Korotkoff sound. It is important to assess the situation further before making adjustments.
Choice C rationale:
Reinflate the cuff to a higher number. Reinflating the cuff to a higher number without addressing the auscultatory gap can result in an inaccurate reading. The presence of an auscultatory gap should be noted and managed appropriately.
Choice D rationale:
Note the presence of an auscultatory gap. This is the correct choice. An auscultatory gap is a temporary disappearance of sounds during the blood pressure measurement, and it may indicate underlying cardiovascular issues. The nurse should note its presence, document it, and take appropriate action if necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Assigning a client who is one day postoperative for a laparoscopic cholecystectomy to the practical nurse (PN) is appropriate. This procedure is minimally invasive, and the client is likely stable, requiring routine postoperative care such as wound assessment, pain management, and monitoring for any signs of complications.
Choice B rationale:
An older client who is one day postoperative with a colostomy for colon cancer may have complex postoperative needs, including colostomy care, monitoring for complications, and pain management. This level of care is usually within the scope of the registered nurse (RN) rather than a practical nurse (PN).
Choice C rationale:
An older adult who is scheduled for foot amputation due to diabetes complications is likely to have complex care needs, including wound care, diabetes management, and potential complications. This client would require the expertise of an RN rather than a PN.
Choice D rationale:
An adult with alcoholism, cirrhosis, and hepatic encephalopathy may have complex medical and psychosocial issues that require specialized nursing care. This client's condition is not appropriate for a practical nurse (PN) to manage, and the care should be provided by an RN or other specialized healthcare provider.
Correct Answer is D
Explanation
Choice A rationale:
Concerns about parenting. While concerns about parenting are important to address during prenatal care, the initial visit focuses on gathering essential information and providing education related to pregnancy and childbirth. Knowledge about labor and delivery is crucial for the client to understand the process and make informed decisions.
Choice B rationale:
Cultural practices related to childbearing. Cultural practices related to childbearing are also essential topics to discuss during prenatal care, but they may not be the highest priority at the initial visit. Understanding the client's cultural background and beliefs is important, but providing information about pregnancy and childbirth should take precedence during the first prenatal visit.
Choice C rationale:
Complications associated with childbirth. Discussing complications associated with childbirth is important, but it may be overwhelming for a client during the initial prenatal visit. The primary focus should be on providing basic information and addressing immediate questions and concerns, with more in-depth discussions about complications occurring in subsequent visits.
Choice D rationale:
Knowledge about labor and delivery. This is the correct choice because the initial prenatal visit should include education about pregnancy, labor, and delivery. Providing the client with essential knowledge about what to expect during labor and delivery empowers her to make informed decisions and plan for her childbirth experience.
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