The nurse is obtaining a systolic blood pressure by palpation.

While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?

Record a palpable systolic pressure of 90 mm Hg.

Release the manometer valve immediately.

Document the absence of the radial pulse.

Inflate the blood pressure cuff to 120 mm Hg.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Recording a palpable systolic pressure of 90 mm Hg without further action would likely underestimate the true systolic pressure. The nurse should inflate the cuff to a higher pressure to obtain an accurate measurement.
Choice B rationale
Releasing the manometer valve immediately would lead to deflating the cuff and potentially missing the opportunity to obtain an accurate blood pressure measurement.
Choice C rationale
Documenting the absence of the radial pulse is important, but it is also crucial to ensure that blood pressure measurements are obtained correctly. Further action is needed to obtain an accurate measurement.
Choice D rationale
Inflating the blood pressure cuff to 120 mm Hg is the correct action. When the radial pulse becomes unpalpable during cuff inflation, the cuff should be inflated to a higher pressure (usually 20-30 mm Hg above the point where the radial pulse disappears) and then slowly deflated while palpating for the return of the radial pulse.

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Correct Answer is []

Explanation

Most Likely Condition:

The client is most likely experiencing Hospital-acquired pneumonia ©. This is indicated by the recent admission for pneumonia, persistent cough with greenish sputum, increased WBC count, and bilateral infiltrates on the chest X-ray.

Actions to Take:

Administer IV antibiotics as prescribed (already in the provider’s prescriptions).
Perform chest physiotherapy © to help clear the lungs.

Parameters to Monitor:

Oxygen saturation (A) to ensure the client is maintaining adequate oxygen levels.
White blood cell count (D) to monitor the infection and response to antibiotics.

A. Verify placement of pulse oximeter. B. Increase the oxygen to 3 L/minute. C. Remove nasal cannula. D. Switch to a non-rebreather mask.

Correct Answer is A

Explanation

Choice A rationale
Verifying the placement of the pulse oximeter is the first step to ensure accurate readings. Incorrect placement can lead to false low oxygen saturation readings.
Choice B rationale
Increasing the oxygen to 3 L/minute may be necessary if the oxygen saturation remains low after verifying the pulse oximeter placement. However, it is not the immediate first step.
Choice C rationale
Removing the nasal cannula is not appropriate as it would further decrease the oxygen supply to the patient.
Choice D rationale
Switching to a non-rebreather mask is not the immediate action to take. Non-rebreather masks deliver a high concentration of oxygen, typically reserved for severe hypoxia.

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The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client in the intensive care unit. Exhibits Complete the diagram by specifying which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.

Correct Answer is []

Explanation

The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?

Correct Answer is A

Explanation

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The nurse is obtaining a systolic blood pressure by palpation.

While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?