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.

Answer and Explanation

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.

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Correct Answer is ["A","D"]

Explanation

A. Overweight or obesity is a modifiable risk factor. It can be addressed through lifestyle changes such as diet modification, increased physical activity, and behavioral interventions aimed at weight loss.

D. Smoking is a modifiable risk factor. It is within an individual's control to quit smoking, which can significantly reduce the risk of various health problems, including cancer.

B. A history of prostate cancer is not a modifiable risk factor. Once a person has had prostate cancer, it cannot be changed through lifestyle modifications or interventions.

C. Being male is a non-modifiable risk factor for prostate cancer. Gender is determined biologically and cannot be changed.

E. Age is a non-modifiable risk factor. As individuals age, they are naturally at higher risk for certain health conditions, including prostate cancer. Age cannot be changed through interventions.

A. Axillary B. Skin C. Oral D. Rectal

Correct Answer is D

Explanation

D. Rectal temperature measurement involves inserting a thermometer into the rectum. This method provides the most accurate reflection of core body temperature because the rectum closely mirrors internal body temperature. It is often used in infants, young children, and patients who are unable to have their temperature taken orally.

A. Axillary temperature measurement involves placing the thermometer in the armpit. This method is convenient and non-invasive but tends to provide the lowest temperature readings compared to other sites. It is suitable for screening purposes but may not be as accurate as other methods.

B. Skin temperature can vary widely based on environmental factors, circulation, and local skin conditions. Surface skin temperature may not accurately reflect core body temperature and is not typically used for precise temperature measurement in clinical settings.

C. Oral temperature measurement involves placing the thermometer under the tongue. This method is commonly used and provides a reasonably accurate reflection of core body temperature. It is convenient and generally well-tolerated by clients who are conscious and able to cooperate.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a 74-year-old male client. The client has a family history of prostate cancer, is 50 pounds overweight and history of smoking tobacco X 60 years. Which of the following are modifiable risk factors for this client's health? (SELECT ALL THAT APPLY)

Correct Answer is ["A","D"]

Explanation

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Correct Answer is D

Explanation

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