The nurse, while obtaining the blood pressure reading of a client, is uncertain when the muffled sounds have ended. What is the nurse's best action at this time?
pump the cuff up again immediately before releasing it.
use the client's radial pulse to determine how high to pump up the cuff
obtain another cuff and take the blood pressure again in 30 minutes.
release the cuff completely and wait two minutes before retaking the blood pressure.
The Correct Answer is D
D. When uncertain about the endpoint of Korotkoff sounds, releasing the cuff completely allows the blood flow to return to normal in the arm. After waiting for about two minutes, the nurse can reinflate the cuff and begin the measurement process again. This approach helps ensure accurate measurement by resetting conditions and allowing for a clearer determination of when Korotkoff sounds start and stop.
A. This option is not recommended because re-inflating the cuff immediately could lead to incorrect readings due to inaccurate pressure settings or discomfort for the client. It does not address the issue of determining the endpoint of the Korotkoff sounds.
B. This technique involves palpating the radial pulse while inflating the cuff and then inflating the cuff until the pulse is no longer palpable. This method can help ensure the cuff is inflated to an appropriate pressure level, which is typically about 30 mmHg above the point where the radial pulse disappears.
However, this option does not directly address the uncertainty about when to listen for the Korotkoff sounds to stop.
C. This option is not practical for addressing the immediate uncertainty during the current blood pressure measurement. Waiting 30 minutes to retake the blood pressure with a different cuff may delay necessary assessment and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Yogurt contains probiotics, which are beneficial bacteria that can help restore and maintain a healthy balance of gut flora. Consuming yogurt with live cultures regularly is a recognized strategy to replenish beneficial bacteria in the gut, especially after a period of diarrhea or antibiotic use that may disrupt the normal gut microbiota.
A. This statement is related to the management of infection and antibiotic therapy, not specifically to reestablishing bowel flora. While stopping antibiotics appropriately is important for overall health and possibly reducing antibiotic-associated diarrhea, it does not directly address the replenishment of bowel flora.
B. Rice is often recommended during episodes of diarrhea to provide bland, easily digestible food. However, it does not actively contribute to reestablishing healthy bowel flora. It helps in managing symptoms but does not address the restoration of beneficial gut bacteria.
D. Hydration is essential during episodes of diarrhea to prevent dehydration. While adequate hydration supports overall health and can aid in recovery, it does not specifically address the restoration of bowel flora.
Correct Answer is A
Explanation
A. Vitamin D is often referred to as the "sunshine vitamin" because the body produces it in response to sunlight exposure on the skin. Spending more time indoors reduces sunlight exposure, which can lead to insufficient production of vitamin D in the body. Vitamin D is important for bone health, immune function, and other physiological processes.
B. Vitamin E deficiency is rare in healthy individuals with a balanced diet. It is primarily found in foods such as nuts, seeds, and vegetable oils. Deficiency can occur in conditions where fat absorption is impaired or in certain genetic disorders.
C. There are several B vitamins (e.g., B1, B2, B6, B12) that are essential for various metabolic processes in the body. Deficiencies in specific B vitamins can occur due to inadequate dietary intake, malabsorption
disorders, or other medical conditions. However, preference for indoor activities does not directly correlate with increased risk of vitamin B deficiency.
D. Vitamin A deficiency is more commonly associated with inadequate intake of foods rich in vitamin A (e.g., liver, carrots, sweet potatoes) rather than sunlight exposure. Vitamin A is important for vision, immune function, and cellular growth.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.