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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Placing a client in restraints without having a healthcare provider's order is not a tort, but a violation of the client's rights. The nurse should obtain an order for restraints as soon as possible and follow the facility's policy and procedure.

Choice B reason: Informing a client that the medication being administered is a vitamin is a tort, specifically a fraud. The nurse is deceiving the client and violating the principle of informed consent. The nurse should explain the purpose, benefits, and risks of the medication to the client and obtain the client's consent.

Choice C reason: Enlisting security personnel to assist with restraining the client is not a tort, but a prudent action. The nurse is ensuring the safety of the client and others by seeking help from trained staff. The nurse should document the incident and the rationale for the intervention.

Choice D reason: Administering the medication to a client behind a closed curtain is not a tort, but a respectful action. The nurse is maintaining the client's privacy and dignity by providing a quiet and secluded environment. The nurse should monitor the client's response and report any adverse effects.

A. Provide oral sponge toothettes so the client can cleanse and moisten his mouth. B. Teach the client that the oral mucosa must remain dry to prevent aspiration. C. Turn the suction off while allowing the client to rinse his mouth with cool water. D. Instill 50 ml of normal saline solution into the tube and clamp the tube for one hour.

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.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

The nurse is preparing to give an emergency sedative injection to an agitated client. Which action by the nurse comprises a tort?

Correct Answer is B

Explanation

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

The nurse is teaching a client about how to use crutches. Which action performed by the client demonstrates to the nurse a correct understanding of how to use the crutches?

A client who is on complete bedrest frequently calls the nurse for the bedpan to urinate. Which action should the nurse take to evaluate the client for urinary retention?

The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?

The healthcare provider prescribes a 24-hour urine specimen to be collected for creatinine clearance. The client is eager to go home and tells the nurse that the first sample was put in the urinal 2 hours ago. Which action should the nurse implement?

The nurse is preparing to administer hydrocodone to a client admitted with urolithiasis who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client?

The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which action is most useful for the nurse to include during the teaching session?

The nurse is evaluating the fluid balance of a client who was admitted yesterday with dehydration and who has been receiving IV fluids since admission. An increase in which parameter indicates to the nurse that the client is rehydrating?

After administering oxycodone to a client one hour ago, the client is reporting severe pain. Which intervention should the nurse implement next?