When auscultating the blood pressure of a 25-year-old, the nurse hears the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg the Korotkoff sounds muffle. At 92 mm Hg the Korotkoff sounds disappear. How should the nurse record this patient's blood pressure?
200/92
100/200/92
200/100
200/100/92
The Correct Answer is D
A. 200/92. This format does not include the muffling point (Phase IV), which is important in some clinical settings, such as in critically ill patients or those with vascular diseases.
B. 100/200/92. This order is incorrect because the systolic pressure should always be listed first, followed by the diastolic components.
C. 200/100. This format omits the point at which sounds completely disappear (Phase V), which is the true diastolic pressure in most cases. However, in some individuals, particularly those with conditions like aortic regurgitation, the muffling point may be recorded as an additional reading.
D. 200/100/92. The correct way to document blood pressure when Korotkoff sounds muffle before disappearing is to include all three values: the systolic pressure (Phase I), the point of muffling (Phase IV), and the diastolic pressure (Phase V). This ensures a complete and accurate blood pressure recording.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Brachial artery. The brachial pulse is commonly used in infants but is not the best choice for assessing circulation in an unconscious adult.
B. Carotid artery. The carotid artery is the preferred site for assessing a pulse in an unconscious adult because it is a central pulse with strong circulation, even in low-perfusion states.
C. Radial artery. The radial pulse is a peripheral pulse and may be difficult to palpate if the patient has poor circulation or cardiac arrest. The carotid pulse is more reliable in emergencies.
D. Apical artery. There is no apical artery; the apical pulse is auscultated over the heart with a stethoscope and is not used in emergency pulse checks.
Correct Answer is C
Explanation
A. Hyperventilation. Opioid overdose depresses the central nervous system, leading to slow and shallow breathing, not increased respiratory rate (hyperventilation).
B. Eupnea. Eupnea refers to normal breathing, which is unlikely in opioid overdose because opioids suppress respiratory drive.
C. Bradypnea. Opioids act on the brainstem's respiratory centers, leading to respiratory depression, characterized by slow breathing (bradypnea) and, in severe cases, respiratory arrest. This is the most life-threatening effect requiring immediate intervention.
D. Hyperpnea. Hyperpnea refers to deep breathing, which is not a typical response to opioid overdose. Instead, breathing becomes slow and shallow, increasing the risk of hypoxia.
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