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 ["A","C","E"]
Explanation
Choice A Reason: This is correct because providing comfort measures such as topical warm application and tactile massage can help reduce pain perception and promote relaxation by stimulating non-painful sensory receptors.
Choice B Reason: This is incorrect because assisting the client to ambulate as much as possible during waking hours can increase pain intensity and fatigue by aggravating inflamed or injured tissues. The nurse should encourage moderate physical activity within the client's tolerance level.
Choice C Reason: This is correct because determining client's subjective measure of pain using a numerical pain scale can help assess pain severity and effectiveness of pain management interventions. Pain is a subjective experience that varies among individuals.
Choice D Reason: This is incorrect because encouraging increased fluid intake and measuring urinary output every 8 hours are not directly related to pain management. These interventions are more relevant for clients with fluid imbalance or renal impairment.
Choice E Reason: This is correct because implementing a 24-hour schedule of routine administration of prescribed analgesic can help maintain a steady level of analgesia and prevent breakthrough pain. Chronic pain requires continuous treatment rather than on-demand administration.
Correct Answer is ["B"]
Explanation
Choice A Reason: This is incorrect because nociceptive pain is caused by stimulation of nociceptors, which are sensory receptors that respond to tissue damage or inflammation. Nociceptive pain is usually localized and throbbing or aching.
Choice B Reason: This is correct because neuropathic pain is caused by damage or dysfunction of the nervous system. Neuropathic pain is usually diffuse and burning or shooting.
Choice C Reason: This is incorrect because acute pain is defined by its duration rather than its cause or quality. Acute pain lasts less than six months and usually has an identifiable cause and predictable course.
Choice D Reason: This is incorrect because visceral pain is caused by stimulation of nociceptors in the internal organs. Visceral pain is usually deep and cramping or squeezing.
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