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 B
Explanation
Choice A rationale:
“I should take this medication with food to prevent stomach upset.” Rationale: This statement is not accurate for fluconazole. While some medications should be taken with food to reduce stomach upset, fluconazole is typically taken on an empty stomach. Taking it with food may reduce its absorption.
Choice B rationale:
“I should avoid drinking alcohol while taking this medication.” Rationale: This is the correct response. Fluconazole can interact with alcohol and may lead to increased side effects or reduced effectiveness of the medication. Therefore, it is essential to avoid alcohol while taking fluconazole.
Choice C rationale:
“I should use a barrier method of contraception while taking this medication.” Rationale: While it is generally a good practice to use barrier contraception during treatment for a fungal infection to prevent potential spread to a partner, this statement does not specifically address fluconazole's requirements or interactions.
Choice D rationale:
“I should stop taking this medication if I develop a rash.” Rationale: This statement is not entirely accurate. While it is important to monitor for skin rashes as they can be a sign of an allergic reaction, the decision to stop taking fluconazole should be made in consultation with a healthcare provider. It is not an automatic response to developing a rash.
Correct Answer is D
Explanation
Step 1 is to convert the child’s weight from pounds to kilograms since the dosage is prescribed in mg/kg. We know that 1 kg is approximately 2.2 lbs. So, the child’s weight in kg is 55 lbs ÷ 2.2 = 25 kg (rounded to the nearest whole number for simplicity).
Step 2 is to calculate the total daily dosage. The prescription is for 150 mg/kg/day. So, the total daily dosage is 150 mg/kg/day × 25 kg = 3750 mg/day.
So, the correct answer is, after analysing all choices, the nurse should administer 3750 mg of cefotaxime each day.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.