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 B

Explanation

B. This is the initial phase of the nurse-client relationship where the individuals first meet. It is characterized by establishing rapport, clarifying roles, setting goals, and developing an agreement or contract for the relationship.

A. This phase occurs towards the end of the nurse-client relationship when goals have been achieved or the relationship is ending for other reasons. It involves summarizing, evaluating progress, and saying goodbye.

C. This phase follows the orientation phase. It is characterized by actively working together to achieve mutually agreed upon goals. During this phase, the nurse and client explore issues, develop and implement solutions, and evaluate progress towards goals.

D. This phase occurs before the nurse and client meet formally. It involves gathering information about the client from various sources, such as medical records or other healthcare professionals.

A. Place the patient in a negative pressure room. B. Use droplet precautions when the pathogen can be spread via sneezing, coughing or talking. C. Use droplet precautions to control the spread of infections that are transmitted person-to- person on air currents. D. An N-95 mask should be worn. E. Wear a surgical mask when working within 3 feet of the patient.

Correct Answer is ["B","E"]

Explanation

B Droplet precautions are used for pathogens that can be transmitted through respiratory droplets produced when an infected person coughs, sneezes, talks, or during procedures such as suctioning.

E. Healthcare workers should wear a surgical mask when within close proximity (within 3 feet) of a patient on droplet precautions. The mask helps prevent the inhalation of droplets that may contain infectious pathogens.

A. Negative pressure rooms are used for airborne precautions, not droplet precautions. Droplet precautions typically do not require negative pressure rooms.

C. Infections transmitted on air currents are managed with airborne precautions, not droplet precautions. Droplet transmission occurs over shorter distances (generally within 3 feet) due to larger respiratory droplets.

D. An N-95 mask is used for airborne precautions to filter smaller particles. For droplet precautions, healthcare workers typically wear a surgical mask to protect against larger respiratory droplets.

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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 phase of the nurse-client relationship that begins when the individuals first meet, and that is characterized by an agreement to continue meeting and assessing needs is the:

Correct Answer is B

Explanation

A nurse educator is teaching student nurses about droplet precautions. The educator emphasizes the differences between indications for droplet precautions versus airborne precautions. Which of the following statements about droplet precautions are correct? (SELECT ALL THAT APPLY)

Correct Answer is ["B","E"]

Explanation

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