Older adult patients with hypertension may have an auscultatory gap in their Korotkoff sounds. It is important when taking their blood pressure measurement to:
pump up the cuff until no sound is heard and then let the air out.
stop midway and begin to inflate again.
make sure the bell of the stethoscope is placed firmly over the artery.
continue to listen until the cuff is deflated.
The Correct Answer is D
Rationale
A. Pumping the cuff until no sound is heard may cause inaccurate readings and is not a proper technique.
B. Stopping midway can result in missing sounds or causing an inaccurate measurement.
C. The bell of the stethoscope should be used for low-pitched sounds, but the key is to continue listening to identify the full Korotkoff sound range, especially in the presence of an auscultatory gap.
D. It is important to continue listening until the cuff is deflated to ensure the accurate measurement of both systolic and diastolic pressures, particularly in patients with an auscultatory gap.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Temperature monitoring is important but not a top priority when a patient is receiving opiates unless there is suspicion of infection.
B. Pulse monitoring is also important but does not immediately indicate issues with opiate use.
C. Blood pressure is influenced by opiate use, but the primary concern is respiratory function due to the risk of respiratory depression.
D. Respirations should be closely monitored because opiates can significantly depress the respiratory system, leading to hypoventilation or respiratory arrest, which is the most critical risk.
Correct Answer is A
Explanation
A. Allowing the patient to sit on the side of the bed helps to prevent sudden drops in blood pressure and allows the body to adjust to the change in position, reducing the risk of fainting or dizziness.
B. Using a wheelchair for mobility may not address the root cause of orthostatic hypotension and may limit the patient's independence.
C. Keeping the patient in a high Fowler's position could worsen the symptoms of orthostatic hypotension.
D. Rising quickly could lead to a sudden drop in blood pressure and increase the risk of a fall or injury.
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