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: Have the client hold a pillow over the abdomen to cough and deep breathe is not the most important instruction because it is not related to repositioning. This is a good practice to prevent respiratory complications after surgery, but it can be done at any time.

Choice B: Encourage the client to eat all of the meals that are sent is not the most important instruction because it is not related to repositioning. This is a good practice to promote nutrition and healing after surgery, but it can be done at any time.

Choice C: Offer fruit juice at least twice during both the day and evening shifts is not the most important instruction because it is not related to repositioning. This is a good practice to prevent dehydration and constipation after surgery, but it can be done at any time.

Choice D: Lower the bed prior to helping the client to move up in bed is the most important instruction because it reduces the risk of injury and falls for both the client and the UAP. This is a safety measure that should be done before any repositioning.

A. Removes needle before discarding used syringes. B. Wears gloves to dispose of the needle and syringe. C. Washes hands before handling the needle and syringe. D. Dons a face mask before administering the medication.

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because removing needle before discarding used syringes may expose the client or others to accidental needlestick injuries. The needle and syringe should be disposed of as a single unit in a puncture-resistant container.

Choice B Reason: This is incorrect because wearing gloves to dispose of the needle and syringe is not necessary if the client does not have contact with blood or body fluids. Gloves are not a substitute for hand hygiene.

Choice C Reason: This is correct because washing hands before handling the needle and syringe reduces the risk of infection and contamination. Hand hygiene is the most important measure to prevent transmission of microorganisms.

Choice D Reason: This is incorrect because donning a face mask before administering the medication is not required unless the medication is aerosolized or nebulized. A face mask does not protect against needlestick injuries or bloodborne pathogens.

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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?

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Naxlex Comprehensive Predictor Exams

A client who had surgery 3 days ago is sitting with head of bed at 75 degrees and requests to be repositioned. Which instruction is most important for the nurse to provide to the unlicensed assistive personnel (UAP)?

Correct Answer is D

Explanation

The nurse is teaching a client about use of the syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

Correct Answer is C

Explanation

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