After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound.
Which action should the nurse take next?

Continue with the blood pressure assessment.

Reposition the stethoscope over the brachial artery.

Reinflate the cuff to a higher number.

Note the presence of an auscultatory gap.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Continue with the blood pressure assessment. Continuing with the blood pressure assessment without addressing the observed auscultatory gap could lead to an inaccurate reading. It's important to investigate and note the presence of an auscultatory gap before proceeding with the assessment.

Choice B rationale:

Reposition the stethoscope over the brachial artery. Repositioning the stethoscope may not resolve the issue of hearing silence followed by a Korotkoff sound. It is important to assess the situation further before making adjustments.

Choice C rationale:

Reinflate the cuff to a higher number. Reinflating the cuff to a higher number without addressing the auscultatory gap can result in an inaccurate reading. The presence of an auscultatory gap should be noted and managed appropriately.

Choice D rationale:

Note the presence of an auscultatory gap. This is the correct choice. An auscultatory gap is a temporary disappearance of sounds during the blood pressure measurement, and it may indicate underlying cardiovascular issues. The nurse should note its presence, document it, and take appropriate action if necessary.

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Correct Answer is B

Explanation

Choice A rationale:

Diarrhea and flatulence are common side effects of statin medications like lovastatin but are typically not considered emergencies. They may be managed with dietary adjustments or over-the-counter remedies.

Choice B rationale:

Muscle pain, especially if severe, requires the most immediate follow-up by the nurse. Muscle pain can be a symptom of a rare but serious side effect called rhabdomyolysis, which can lead to muscle breakdown and potential kidney damage. Prompt assessment and intervention are necessary if severe muscle pain occurs.

Choice C rationale:

Altered taste is a side effect of lovastatin but is generally not considered a medical emergency. It may affect the client's quality of life but does not require immediate follow-up.

Choice D rationale:

Abdominal cramps may occur as a side effect of lovastatin, but they are not typically considered an emergency. Like choice A, abdominal cramps can often be managed with dietary adjustments or over-the-counter remedies.

A. Objective data B. Subjective data C. Primary data D. Secondary data.

Correct Answer is B

Explanation

Choice A rationale:

Objective data. Rationale: Objective data are observable and measurable facts obtained through physical examination or diagnostic tests. The statement incorrectly labels the data as objective when it is, in fact, based on the client's feelings and perceptions, making it subjective.

Choice B rationale:

Subjective data. Rationale: Subjective data are information provided by the client, including their feelings, perceptions, and experiences. The statement correctly labels the data as subjective, as it reflects the client's report of thirst and hunger.

Choice C rationale:

Primary data. Rationale: Primary data are original data collected directly from the source, such as a client's medical history or interview. However, this classification does not address the nature of the data as being subjective or objective, so the statement does not provide a complete answer.

Choice D rationale:

Secondary data. Rationale: Secondary data are data obtained from sources other than the client, such as medical records or research studies. Similar to choice C, this classification does not address the nature of the data as being subjective or objective.

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After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound.
Which action should the nurse take next?