A nurse is measuring the blood pressure of a client and hears faint, clear tapping sounds at 110 mm Hg and then silence. What does this indicate?

The equipment is malfunctioning.

The systolic blood pressure is 110 mm Hg.

The diastolic blood pressure is 110 mm Hg

The blood pressure cuff is too loose.

Answer and Explanation

The Correct Answer is B

A. There is no indication of equipment malfunction; the nurse is able to hear Korotkoff sounds, which indicates proper functioning of the sphygmomanometer and stethoscope.

B. The first faint, clear tapping sound heard when inflating and then slowly deflating the cuff represents the systolic blood pressure. In this scenario, the systolic pressure is 110 mm Hg, indicating the pressure at which the heart is pumping blood into the arteries.

C. The diastolic blood pressure is recorded when the sounds disappear, not when they first appear. Therefore, 110 mm Hg is not the diastolic value.

D. While a cuff that is too loose can affect accuracy, the presence of clear tapping sounds suggests that the cuff fit is adequate for obtaining a measurement.

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Correct Answer is C

Explanation

A. Using a cotton-tipped applicator to remove cerumen can cause trauma to the ear canal and is not recommended for routine temperature measurement.

B. Inserting the probe with a circular motion is incorrect; tympanic thermometers should be inserted gently in line with the ear canal, not rotated.

C. Aiming the probe posteriorly toward the eardrum ensures accurate measurement of the tympanic membrane temperature, as the sensor must detect infrared radiation from the eardrum, which reflects core body temperature.

D. Pulling the pinna downward and backward is appropriate for children under 3 years, not for adult clients. In adults, the pinna should be pulled upward and backward to straighten the ear canal.

A. Eddie Bernice Johnson B. Dorothea Dix C. Clara Barton D. Florence Nightingale

Correct Answer is C

Explanation

A. Eddie Bernice Johnson is a U.S. Congresswoman, not a historical contributor to nursing or the Red Cross.

B. Dorothea Dix was a social reformer and advocate for the mentally ill and for military hospitals during the Civil War, but she did not found the American Red Cross.

C. Clara Barton founded the American Red Cross in 1881 and played a significant role in providing emergency care and disaster relief, establishing the organization as a cornerstone of humanitarian aid.

D. Florence Nightingale is known as the founder of modern nursing and for her work during the Crimean War, but she did not establish the American Red Cross.

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A nurse is measuring the blood pressure of a client and hears faint, clear tapping sounds at 110 mm Hg and then silence. What does this indicate?

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