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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Regular exercise:

Regular exercise is important for overall cardiovascular health and can help reduce the risk of developing heart disease. However, smoking cessation is more crucial because smoking is a significant risk factor for heart disease and quitting smoking has immediate and long-term benefits for heart health.

B. Smoking cessation:

Smoking is a major risk factor for heart disease as it damages the blood vessels, increases blood pressure, reduces oxygen supply to the heart, and promotes the formation of blood clots. Encouraging smoking cessation is essential for reducing the risk of heart disease and improving overall health.

C. Low-fat diet:

Adopting a low-fat diet can help lower cholesterol levels and reduce the risk of heart disease, but it may not be as critical as smoking cessation for individuals with a family history of cardiac disease.

D. Stress reduction:

While stress reduction techniques such as relaxation exercises, meditation, and mindfulness can be beneficial for heart health, addressing smoking cessation is more urgent for individuals with a family history of cardiac disease, as smoking is a more significant risk factor for heart disease.

A. How many popsicles are available. B. If the popsicles are completely frozen. C. The color and flavor of gelatin used. D. Whether they contain pulp or fruit.

Correct Answer is D

Explanation

A. How many popsicles are available.

This information might be helpful for logistical purposes or to assess how much the child has consumed, but it's not directly relevant to ensuring the appropriateness of the popsicles for a clear liquid diet.

B. If the popsicles are completely frozen.

While it's important that popsicles are properly frozen to avoid potential choking hazards, this does not address whether the popsicles meet the dietary requirement of clear liquids.

C. The color and flavor of gelatin used.

While this might be of interest, the key concern is whether the popsicles contain any non-clear components like fruit or pulp.

D. Whether they contain pulp or fruit.

For a child who needs clear liquids, it is important to ensure that the popsicles do not contain any solids like fruit or pulp. Clear liquids are meant to be easily digestible and not irritate the stomach further. Popsicles with pulp or fruit can be too heavy and might not be appropriate in this situation.

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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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