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. The half-life of a drug refers to the time it takes for the concentration of the drug in the bloodstream to be reduced by half. If a medication has a long half-life, it means that it stays in the body for a longer period before being eliminated. This allows for less frequent dosing intervals while still maintaining therapeutic effectiveness.
A. Drugs with a short half-life are typically cleared from the body more quickly. While they may require more frequent dosing to maintain therapeutic levels, they do not necessarily have a greater risk for toxicity compared to drugs with longer half-lives. In fact, drugs with longer half-lives can accumulate in the body over time, potentially increasing the risk of toxicity.
B. The half-life of a drug can be significantly influenced by renal (kidney) and hepatic (liver) function. Impaired renal or hepatic function can prolong the half-life of a drug, leading to slower elimination and potentially increased risk of adverse effects.
D. This statement describes the concept of drug metabolism rather than the half-life. Drug metabolism refers to the biochemical alteration of drugs by enzymes, often occurring in the liver. The half-life, on the other hand, specifically relates to the elimination of the drug from the body.
Correct Answer is A
Explanation
A. Giving a written warning is a serious disciplinary action that should only be considered after other steps to support and assist the assistant have been taken. It does not promote a supportive or constructive approach to resolving the issue.
B. This option involves the nurse providing guidance and support to the assistant. By acting as a role model, the nurse can demonstrate the correct way to approach the task and provide alternative solutions or techniques. This approach encourages learning and professional development for the assistant.
C. While this may temporarily resolve the issue, it does not address the assistant's competency or provide an opportunity for learning and growth. It may also undermine the assistant's confidence and independence in performing the task.
D. While providing another task might offer another chance for success, it does not directly address the current difficulty with the delegated task. The nurse should focus on addressing the specific challenge at hand before assigning additional tasks.
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