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?

Release the manometer valve immediately.

Document the absence of the radial pulse.

Inflate the blood pressure cuff to 120 mm Hg.

Record a palpable systolic pressure of 90 mm Hg. .

Answer and Explanation

The Correct Answer is C

Choice A rationale

Releasing the manometer valve immediately is not appropriate as it does not allow for an accurate measurement of systolic blood pressure.

Choice B rationale

Documenting the absence of the radial pulse is not the correct action. The nurse needs to continue the procedure to obtain an accurate systolic blood pressure reading.

Choice C rationale

Inflating the blood pressure cuff to 120 mm Hg is the correct action. The nurse should inflate the cuff 30 mm Hg above the point where the radial pulse is no longer palpable to ensure an accurate measurement.

Choice D rationale

Recording a palpable systolic pressure of 90 mm Hg is incorrect. The nurse needs to inflate the cuff further to obtain an accurate systolic blood pressure reading

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Correct Answer is D

Explanation

Choice A rationale

Sending an email to facility administrators reporting the action may not be the most immediate or effective way to address the situation. It could delay the necessary intervention and does not ensure that the issue is resolved promptly.

Choice B rationale

Warning the colleague that copying health information is unlawful is important, but it may not adequately address the potential breach of patient privacy and confidentiality. The colleague may already be aware of the laws but still engage in inappropriate behavior.

Choice C rationale

Disposing of the copies and continuing with client care assignments prevents further unauthorized access to patient information but does not address the issue of the colleague’s inappropriate handling of the records. It is essential to report the incident to the appropriate authority for further investigation and follow-up.

Choice D rationale

Communicating the colleague’s activities to the unit charge nurse is the most appropriate action because it informs the person in charge of the unit about the observed behavior, allowing for immediate intervention and potential corrective action. The unit charge nurse can address the situation promptly and ensure that patient privacy and confidentiality are maintained.

A. Negligent acts of omission. B. Criminal assault and battery. C. Good Samaritan immunity. D. Abandonment of the victim.

Correct Answer is C

Explanation

Choice C rationale

Good Samaritan immunity. The Good Samaritan laws are designed to protect individuals who provide assistance at the scene of an emergency from legal liability, provided they act in good faith and within the scope of their training. In this scenario, the nurse acted to help the victim and then left the scene after EMS arrived, which is generally protected under Good Samaritan laws.

Choice A rationale

Negligent acts of omission. Negligence would require proof that the nurse failed to act in a manner consistent with their training and that this failure directly caused harm to the victim. In this case, the nurse provided assistance and then left the scene after EMS arrived, which does not constitute negligence.

Choice B rationale

Criminal assault and battery. Assault and battery involve intentional harm or offensive contact, which is not applicable in this scenario as the nurse was providing assistance.

Choice D rationale

Abandonment of the victim. Abandonment would require that the nurse left the victim without ensuring that they were in the care of another competent individual. Since the nurse left after EMS arrived, this does not constitute abandonment.

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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?

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Naxlex Comprehensive Predictor Exams

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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?