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?
Document the absence of the radial pulse.
Release the manometer valve immediately.
Inflate blood pressure cuff to 120 mm Hg.
Record a palpable systolic pressure of 90 mm Hg.
The Correct Answer is C
A. Document the absence of the radial pulse:
While it's important to document findings accurately, it's also crucial to ensure that blood pressure measurements are obtained correctly. If the radial pulse becomes unpalpable before reaching the expected systolic pressure, further action is needed to obtain an accurate measurement.
B. Release the manometer valve immediately:
Releasing the manometer valve immediately would lead to deflating the cuff and potentially missing the opportunity to obtain an accurate blood pressure measurement. This action is not appropriate at this stage.
C. Inflate blood pressure cuff to 120 mm Hg:
When the radial pulse becomes unpalpable during cuff inflation, it indicates that the cuff pressure is above the systolic pressure. To accurately determine the systolic pressure, 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.
D. Record a palpable systolic pressure of 90 mm Hg:
If the radial pulse is no longer palpable at 90 mm Hg, this suggests that the true systolic pressure is higher than 90 mm Hg. Recording a palpable systolic pressure of 90 mm Hg without further action would likely underestimate the true systolic pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Suctions secretions from the posterior pharynx:
Suctioning secretions from the posterior pharynx is an appropriate action to maintain airway patency and prevent aspiration in an unconscious client. This action indicates proper understanding of oral care principles.
B. Tests for a gag reflex before performing oral care:
Testing for a gag reflex before performing oral care is an important safety measure, especially in unconscious clients, to prevent aspiration or airway obstruction. This action indicates proper assessment and consideration of the client's protective reflexes.
C. Places the client in a supine position:
Placing an unconscious client in a supine position during oral care can increase the risk of aspiration, as it may impair the client's ability to manage oral secretions. The preferred position for oral care in unconscious clients is typically a side-lying position to facilitate drainage of oral secretions and reduce the risk of aspiration.
D. Uses an oral airway to keep the teeth apart:
Using an oral airway to keep the teeth apart is not a standard practice for oral care in unconscious clients and may not be necessary. Proper positioning of the client's head and jaw manipulation can often provide adequate access for oral care without the need for an oral airway.
Correct Answer is D
Explanation
A. Auscultate the bowel sounds in all four quadrants:
Auscultating bowel sounds is not directly relevant to nasopharyngeal suctioning. This assessment is more appropriate for evaluating gastrointestinal function and is not a priority during airway management procedures.
B. Palpate the client's pedal pulse volume bilaterally:
Palpating pedal pulse volume is not directly relevant to nasopharyngeal suctioning. This assessment is more appropriate for evaluating peripheral vascular perfusion and is not a priority during airway management procedures.
C. Determine the elasticity of the client's skin turgor:
Assessing skin turgor elasticity is not directly relevant to nasopharyngeal suctioning. This assessment is typically performed to evaluate hydration status and is not a priority during airway management procedures.
D. Observe the client's skin and mucous membranes:
This is the most appropriate assessment during nasopharyngeal suctioning. Observing the client's skin and mucous membranes helps monitor for signs of respiratory distress, such as cyanosis, pallor, or increased respiratory effort. It also allows the nurse to assess the effectiveness of airway clearance and potential complications related to the procedure.
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