While assessing a client’s blood pressure using an aneroid sphygmomanometer, the nurse inflates the cuff to an initial reading of 160 mm calibration. Upon release of the air valve, the nurse immediately hears loud Korotkoff sounds. Which action should the nurse implement next?
Release the air and reinflate the cuff to 30 mm Hg above the client’s previous systolic reading.
Continue the blood pressure assessment until the last Korotkoff sound is heard.
Reposition the stethoscope in the antecubital fossa over the palpable brachial pulse point.
Inflate the cuff quickly to a higher mm Hg reading than the previously auscultated systolic sound.
The Correct Answer is A
Choice A reason: This is the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. This indicates that the cuff was not inflated high enough to occlude the arterial blood flow and the initial systolic reading was inaccurate. The nurse should release the air, wait for 15 to 30 seconds, and then reinflate the cuff to 30 mm Hg above the first systolic sound. This will ensure a more accurate measurement of the blood pressure.
Choice B reason: This is not the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. Continuing the blood pressure assessment until the last Korotkoff sound is heard will result in a lower systolic reading and a higher diastolic reading than the actual blood pressure of the client. The nurse should release the air and reinflate the cuff to 30 mm Hg above the first systolic sound.
Choice C reason: This is not the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. Repositioning the stethoscope in the antecubital fossa over the palpable brachial pulse point will not change the fact that the cuff was not inflated high enough to occlude the arterial blood flow. The nurse should release the air and reinflate the cuff to 30 mm Hg above the first systolic sound.
Choice D reason: This is not the correct action to take when the nurse hears loud Korotkoff sounds immediately after releasing the air valve. Inflating the cuff quickly to a higher mm Hg reading than the previously auscultated systolic sound will cause discomfort and pain to the client and may damage the blood vessels. The nurse should release the air and reinflate the cuff to 30 mm Hg above the first systolic sound.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because occult blood is not visible to the naked eye. Waiting for observable blood may delay diagnosis and treatment of gastrointestinal bleeding.
Choice B Reason: This is incorrect because tarry black stool indicates upper gastrointestinal bleeding, which may not be related to the client's condition. Occult blood can be present in any color of stool.
Choice C Reason: This is correct because the nurse should obtain the specimen from the client's current bowel movement, regardless of its color or consistency. The test for occult blood detects hemoglobin in the stool, which may indicate bleeding anywhere along the gastrointestinal tract.
Choice D Reason: This is incorrect because contacting the healthcare provider before obtaining the specimen is unnecessary and may waste time. The nurse should follow the protocol for stool specimen collection and report any abnormal findings to the provider.
Correct Answer is C
Explanation
Choice A Reason: This is incorrect because regular exercise is a beneficial lifestyle modification for preventing and managing cardiac disease, but it is not the most important one. Smoking cessation has a greater impact on reducing the risk of cardiovascular events and mortality.
Choice B Reason: This is incorrect because stress reduction is a helpful lifestyle modification for preventing and managing cardiac disease, but it is not the most important one. Smoking cessation has a more direct effect on improving the function and structure of the blood vessels and heart.
Choice C Reason: This is correct because smoking cessation is the most important lifestyle modification for preventing and managing cardiac disease, as smoking is a major modifiable risk factor that can cause atherosclerosis, hypertension, arrhythmias, thrombosis, and myocardial infarction.
Choice D Reason: This is incorrect because a low-fat diet is a useful lifestyle modification for preventing and managing cardiac disease, but it is not the most important one. Smoking cessation has a stronger influence on lowering the levels of cholesterol and inflammation in the blood.
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