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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale:

Serum sodium level. Rationale: While electrolyte imbalances can be significant, in the context of purulent drainage at a postoperative site, monitoring serum sodium levels is not the top priority. Other laboratory values are more relevant in this situation.

Choice B rationale:

Hematocrit. Rationale: Hematocrit measures the proportion of red blood cells in the blood and is not directly related to wound drainage or infection. It is not the most relevant parameter to assess in this situation.

Choice C rationale:

Neutrophil count. Rationale: Neutrophils are a type of white blood cell that plays a key role in the body's immune response, particularly against bacterial infections. Elevated neutrophil counts can indicate an ongoing infection, so monitoring this value is important when assessing purulent wound drainage.

Choice D rationale:

Platelet count. Rationale: Platelet count measures the number of blood clotting cells in the blood and is not directly related to wound drainage or infection. It is not the most relevant parameter to assess in this situation.

A. “The combination of trimethoprim and sulfamethoxazole has a synergistic effect that inhibits bacterial growth more effectively than either drug alone.”. B. “The combination of trimethoprim and sulfamethoxazole has an additive effect that reduces the dosage and frequency of administration of each drug.”. C. “The combination of trimethoprim and sulfamethoxazole has an antagonistic effect that prevents the development of resistance to either drug.”. D. “The combination of trimethoprim and sulfamethoxazole has a selective effect that targets only the bacteria causing the UTI and spares the normal flora.”.

Correct Answer is A

Explanation

Choice A rationale:

The combination of trimethoprim and sulfamethoxazole has a synergistic effect, which means that the two drugs work together to inhibit bacterial growth more effectively than either drug alone. This combination is commonly used to treat urinary tract infections (UTIs) caused by susceptible bacteria.

Choice B rationale:

The combination of trimethoprim and sulfamethoxazole does not have an additive effect that reduces the dosage and frequency of administration of each drug. Instead, it is prescribed as a fixed combination with specific dosages of each drug.

Choice C rationale:

The combination of trimethoprim and sulfamethoxazole does not have an antagonistic effect that prevents the development of resistance to either drug. In fact, the combination is chosen because it covers a broader spectrum of bacteria and reduces the likelihood of resistance development.

Choice D rationale:

The combination of trimethoprim and sulfamethoxazole does not have a selective effect that targets only the bacteria causing the UTI and spares the normal flora. It affects a wide range of bacteria, including both pathogenic and normal flora.

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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?

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Naxlex Comprehensive Predictor Exams

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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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?