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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Positioning the bell very lightly over the patient's sternum. The bell is best for low-pitched sounds like murmurs, but heartbeats (especially S1 and S2) are better heard with the diaphragm over the apex of the heart, not the sternum.
B. Placing the diaphragm firmly against the patient's skin. The diaphragm is designed to pick up high-pitched sounds like the normal S1 and S2 heart sounds. Pressing firmly helps eliminate external noise and improves sound clarity.
C. Utilizing a stethoscope with the longest possible tubing. Longer tubing can reduce sound transmission quality. Shorter tubing (about 14-18 inches) provides clearer sound.
D. Making sure that the earpieces fit loosely in the nurse's ear canals. Earpieces should fit snugly, not loosely, to ensure optimal sound conduction and block external noise.

A. The nurse should review the patient's vital signs as soon as they are done. B. The nurse assistant should not be responsible for obtaining vital signs. C. The nurse is not responsible if the nurse assistant fails to obtain the vital signs. D. The nurse assistant should determine if the patient's vital signs are abnormal.

Correct Answer is A

Explanation

A. The nurse should review the patient's vital signs as soon as they are done. Even though vital signs can be delegated, the nurse retains accountability for assessing the data, interpreting abnormalities, and determining if further action is needed.
B. The nurse assistant should not be responsible for obtaining vital signs. Nurse assistants can take vital signs if they are properly trained and it is within their scope of practice. However, the nurse remains responsible for interpreting and acting on the results.
C. The nurse is not responsible if the nurse assistant fails to obtain the vital signs. The nurse remains accountable for delegated tasks and must ensure they are completed correctly.
D. The nurse assistant should determine if the patient's vital signs are abnormal. Nurse assistants can report abnormal findings, but they are not responsible for interpreting results or making clinical decisions—this is the nurse’s responsibility.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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