While assessing a client's blood pressure using an aneroid sphygmomanometer, the nurse inflates the cuff to an initial reading of 160 mm Hg. Upon release of the air valve, the nurse immediately hears loud Korotkoff sounds. Which action should the nurse implement next?

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.

Release the air and reinflate the cuff to 30 mm Hg above the client's previous systolic reading.

Answer and Explanation

The Correct Answer is D

Choice A reason: Continuing the blood pressure assessment until the last Korotkoff sound is heard is not the best action to implement next. It may result in an inaccurate measurement of the diastolic pressure, as the cuff pressure may be too low to detect the sound.

Choice B reason: Repositioning the stethoscope in the antecubital fossa over the palpable brachial pulse point is not a necessary action to implement next. It may not affect the accuracy of the blood pressure measurement, as the nurse already hears the Korotkoff sounds clearly.

Choice C reason: Inflating the cuff quickly to a higher mm Hg reading than the previously auscultated systolic sound is not a safe action to implement next. It may cause discomfort and injury to the client, as the cuff pressure may be too high and occlude the blood flow.

Choice D reason: Releasing the air and reinflating the cuff to 30 mm Hg above the client's previous systolic reading is the best action to implement next. It helps to avoid the auscultatory gap, which is a period of silence between the systolic and diastolic pressures. It also ensures that the cuff pressure is high enough to detect the true systolic and diastolic pressures.

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Correct Answer is D

Explanation

Choice A reason: Muscle strength and tone is not the most important assessment for the nurse to perform prior to the application of a heating pad. It may be relevant for some clients who have musculoskeletal problems, but it does not indicate the risk of thermal injury.

Choice B reason: Limitations to range of motion is not the most important assessment for the nurse to perform prior to the application of a heating pad. It may be relevant for some clients who have joint stiffness or pain, but it does not indicate the risk of thermal injury.

Choice C reason: Presence of rebound phenomenon is not the most important assessment for the nurse to perform prior to the application of a heating pad. It is a sign of peritoneal inflammation that occurs when pressure is released from the abdomen. It has nothing to do with the application of a heating pad.

Choice D reason: Degree of neurosensory impairment is the most important assessment for the nurse to perform prior to the application of a heating pad. It indicates the client's ability to perceive heat and pain sensations. If the client has impaired neurosensory function, the nurse should avoid using a heating pad or use it with caution and frequent monitoring.

A. Neuropathic pain B. Visceral pain C. Acute pain D. Nociceptive pain

Correct Answer is A

Explanation

Choice A reason: Neuropathic pain is caused by damage or dysfunction of the nervous system. It is often described as burning, shooting, or tingling sensations. The client's symptoms are consistent with neuropathic pain.

Choice B reason: Visceral pain is caused by stimulation of pain receptors in the internal organs. It is often described as deep, dull, or cramping sensations. The client's symptoms are not consistent with visceral pain.

Choice C reason: Acute pain is caused by a sudden or short-term injury or illness. It is often described as sharp, throbbing, or stabbing sensations. The client's symptoms are not consistent with acute pain.

Choice D reason: Nociceptive pain is caused by stimulation of pain receptors in the skin, muscles, bones, or joints. It is often described as aching, sore, or pressure sensations. The client's symptoms are not consistent with nociceptive pain.

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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 Hg. 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

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

Correct Answer is D

Explanation

A client reports pain, numbness, and tingling sensations in the lower legs. How should the nurse document this finding?

Correct Answer is A

Explanation

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