A nurse is obtaining a client's manual blood pressure and is having difficulty auscultating sounds. Which of the following actions should the nurse take?
Apply the largest cuff available.
Place the arm above the level of the client's heart.
Deflate the cuff quickly.
Use the palpatory method to determine blood pressure.
The Correct Answer is D
A. Incorrect. Avoiding the issue by scheduling the nurses to have fewer shifts together might not address the underlying conflict and could lead to resentment.
B. Incorrect. To auscultate blood pressure accurately, it's essential to follow proper positioning and technique, which typically involves having the client's arm at heart level. Placing the arm above heart level can lead to falsely lower blood pressure readings.
C. Incorrect. While promising more equitable assignments is important, addressing the conflict directly and encouraging collaboration is a more proactive approach.
D. Using the palpatory method, the nurse can feel for the radial pulse while slowly deflating the blood pressure cuff. This helps estimate the systolic blood pressure when Korotkoff sounds are challenging to hear. It provides a rough estimate until clear sounds can be heard and ensures accurate blood pressure measurement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B,C"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}
Explanation
A. Wheezes - Latex Allergy. Wheezing is often associated with allergic reactions, including latex allergy. Latex allergy can cause airway constriction and result in wheezing.
B. Tachycardia - All Thr ee Conditions (Malignant Hyperthermia, Latex Allergy, Hypovolemic Shock). Tachycardia can be a common response to stress or physiological changes. In malignant hyperthermia, tachycardia can occur due to the hypermetabolic state. Latex allergy can cause an anaphylactic reaction leading to tachycardia. In hypovolemic shock, the heart rate increases to compensate for decreased blood volume.
C. Urticaria - Latex Allergy. Urticaria (hives) is a classic sign of an allergic reaction, including latex allergy.
D. Hypercapnia - Malignant Hyperthermia. Hypercapnia (elevated levels of carbon dioxide in the blood) can be a sign of malignant hyperthermia due to increased muscle metabolism and metabolic acidosis.
E. Muscle Rigidity - Malignant Hyperthermia. Muscle rigidity is a hallmark sign of malignant hyperthermia, a rare but potentially life-threatening reaction to certain medications used during anesthesia.
Correct Answer is C
Explanation
A. Incorrect. Ensuring the device inspection sticker is current is important but not the first action to take when there's a potential safety issue.
B. Incorrect. Reporting the defect is important, but immediate action to ensure client safety should come first.
C. Correct. The nurse's first priority should be ensuring client safety. Removing the device from the room prevents any potential harm from using the device with a frayed cord.
D. Incorrect. Initiating a requisition for a replacement is important, but immediate action to ensure safety is a higher priority.
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