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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A Reason: This is incorrect because positioning the head with the chin tilted slightly downward can help prevent aspiration by closing the airway and directing food to the back of the throat.

Choice B Reason: This is incorrect because raising the head of the bed to 60 degrees can help prevent aspiration by using gravity to keep food in the stomach and away from the lungs.

Choice C Reason: This is incorrect because placing food on the unaffected side of the mouth can help prevent aspiration by stimulating the intact nerves and muscles that control swallowing.

Choice D Reason: This is correct because allowing 30 minutes of rest before feeding can increase the risk of aspiration by reducing the client's alertness and coordination. The UAP should feed the client when he or she is awake and responsive.

A. Remind the UAP to dry between the client’s toes completely. B. Advise the UAP that this procedure is damaging to the skin. C. Add skin cream to the basin of water while the foot is soaking. D. Remove the basin of water from the client’s bed immediately.

Correct Answer is D

Explanation

Choice A: Remind the UAP to dry between the client’s toes completely is not the best action because it does not address the risk of spillage and wetness on the bed. Drying between the toes is important to prevent fungal infections, but it can be done after removing the basin.

Choice B: Advise the UAP that this procedure is damaging to the skin is not the best action because it is not accurate and may cause confusion. Soaking the foot in warm water is not harmful to the skin, unless it is too hot or too long.

Choice C: Add skin cream to the basin of water while the foot is soaking is not the best action because it does not solve the problem and may waste the cream. Skin cream should be applied after drying the foot, not mixed with water.

Choice D: Remove the basin of water from the client’s bed immediately is the best action because it prevents potential hazards such as soaking, infection, or electric shock. The nurse should ensure that the bed is dry and clean before continuing with the bath.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes an unlicensed assistive personnel (UAP) feeding a client who had a cerebral vascular accident (CVA) and is at risk for aspiration. Which action by the UAP should the nurse recognize indicates the need for additional teaching?

Correct Answer is D

Explanation

The nurse observes an unlicensed assistive personnel (UAP) who is providing a total bed bath for a confused and lethargic client. The UAP is soaking the client’s foot in a basin of warm water placed on the bed. Which action should the nurse take?

Correct Answer is D

Explanation

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