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 A

Explanation

Choice A reason: Providing oral sponge toothettes is the best action to take. It helps the client to maintain oral hygiene and comfort, and prevents dryness and cracking of the oral mucosa.

Choice B reason: Teaching the client that the oral mucosa must remain dry to prevent aspiration is not a correct action. The oral mucosa needs to be moist to protect it from infection and irritation. Aspiration is prevented by checking the placement of the nasogastric tube and keeping the head of the bed elevated.

Choice C reason: Turning the suction off while allowing the client to rinse his mouth with cool water is not a safe action. It may increase the risk of aspiration and interfere with the function of the nasogastric tube. The suction should only be turned off when necessary, such as during medication administration or tube feeding.

Choice D reason: Instilling 50 ml of normal saline solution into the tube and clamping the tube for one hour is not an appropriate action. It may cause fluid overload, electrolyte imbalance, and abdominal distension. The nasogastric tube should be flushed with 30 ml of water every 4 to 6 hours to maintain patency and prevent clogging.

A. Start collecting the specimen with the next void. B. Begin the collection the next day. C. Observe the sample for sediment. D. Empty the sample into the 24-hour container.

Correct Answer is A

Explanation

The correct answer is A. Start collecting the specimen with the next void.

Choice A reason: The 4-hour urine collection for creatinine clearance should start with an empty bladder. The first urine of the day is discarded and the time is noted. All subsequent urine for the next 4 hours, including the first urine the following day, should be collected. If the first sample was put in the urinal hours ago and was not collected, the nurse should start collecting the specimen with the next void.

Choice B reason: Beginning the collection the next day would delay the test and may not be necessary. The test should ideally start after the first urine of the day is discarded.

Choice C reason: Observing the sample for sediment is not typically part of the procedure for a 4-hour urine collection for creatinine clearance. The focus is on collecting all urine for a specified period, not on the physical characteristics of the sample.

Choice D reason: Emptying the sample into the 4-hour container would be incorrect if the sample was the first urine of the day, which should be discarded. The collection should start with the next void.

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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?

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Naxlex Comprehensive Predictor Exams

A male client with a nasogastric tube connected to low intermittent suction tells the nurse that his mouth is very dry. Which action should the nurse implement?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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