A nurse is assessing a client's blood pressure using a manual sphygmomanometer and a stethoscope. What action should the nurse take to obtain an accurate blood pressure reading?
Inflate the cuff to 20 mmHg above the estimated systolic pressure.
Deflate the cuff at a rate of 10-20 mmHg per second.
Place the bell of the stethoscope over the brachial artery.
Palpate the radial artery while auscultating for Korotkoff sounds.
The Correct Answer is C
Answer: c. Place the bell of the stethoscope over the brachial artery.
Explanation: To obtain an accurate blood pressure reading, the nurse should place the bell of the stethoscope over the brachial artery, which is located in the antecubital fossa.
a. Inflating the cuff to 20 mmHg above the estimated systolic pressure may be appropriate for initial inflation, but the cuff should be inflated further until the radial pulse disappears, and then slowly deflated to obtain accurate readings.
b. Deflating the cuff at a rate of 2-3 mmHg per second is recommended to obtain accurate blood pressure readings.
d. Palpating the radial artery while auscultating for Korotkoff sounds is not necessary for accurate blood pressure measurement and may interfere with accurate assessment.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
indicate poor sensor placement or a faulty pulse oximeter. The nurse should reapply the pulse oximeter on a different finger to obtain an accurate reading.
a. An irregular waveform is not a normal variation and should be investigated further.
c. Assessing the client for signs of respiratory distress is important but may not directly address the irregular waveform.
d. Notifying the healthcare provider may be necessary if the issue persists after reapplying the pulse oximeter.
Correct Answer is C
Explanation
Answer: c. Notify the healthcare provider of the significant difference.
Explanation: A significant difference in blood pressure readings between the right and left arms may indicate arterial occlusion or other circulatory abnormalities. The nurse should notify the healthcare provider for further evaluation and intervention.
a. Rechecking the blood pressure with a different cuff size may be appropriate if the initial readings were inaccurate, but it does not address the significant difference between the arms.
b. Documenting the finding is important, but further action is required to investigate the cause of the discrepancy.
d. Performing a Doppler ultrasound may be done as part of the diagnostic process to assess blood flow, but the healthcare provider should be notified first for appropriate evaluation.
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