For a client with a previous blood pressure of 138/74 mmHg and pulse of 64 beats/min, approximately how long should the nurse take to release the blood pressure cuff in order to obtain an accurate reading?
10–20 seconds
30–45 seconds
1–A.5 minutes
3–C.5 minutes
The Correct Answer is B
Accurate blood pressure (BP) measurement is a fundamental nursing skill. If the cuff is deflated too quickly, the nurse may miss the first Korotkoff sound (systolic BP) or inaccurately estimate diastolic pressure. Deflating the cuff too slowly can cause venous congestion, discomfort, and a falsely high diastolic reading. Best practice guidelines recommend a cuff deflation rate of 2–3 mmHg per second to ensure an accurate reading without patient discomfort.
Rationale for correct answer:
B. 30–45 seconds: This is the recommended time frame for releasing the cuff when using a 2–3 mmHg/second deflation rate, which allows clear identification of both systolic and diastolic sounds.
Rationale for incorrect answers:
A. 10–20 seconds: Deflating the cuff this quickly equates to a deflation rate that is too fast (greater than 5 mmHg per second). This may result in missing Korotkoff sounds and underestimating the true BP values, especially systolic pressure.
C. 1 -- A.5 minutes: Deflating the cuff this slowly would equate to less than 1 mmHg per second, which is unnecessarily prolonged. It can cause venous congestion, discomfort, and may lead to a falsely elevated diastolic pressure.
D. 3–C.5 minutes: This is excessively slow and not clinically appropriate.
Take-home points:
- The blood pressure cuff should be deflated at a rate of 2-3 mmHg per second, resulting in a total release time of approximately 30-45 seconds, depending on the pressure range.
- Incorrect deflation rates (too fast or too slow) can lead to inaccurate readings and impact clinical decisions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The Point of Maximal Impulse (PMI), also referred to as the apical impulse, is the location on the chest wall where the heartbeat is most strongly felt or heard. It corresponds to the apex of the heart, typically located at the 5th intercostal space, midclavicular line in adults
Rationale for correct answers:
E. Near apex: This point corresponds to the 5th intercostal space at the midclavicular line, where the apex of the heart contacts the chest wall. It is the most accurate site for auscultating the apical pulse and evaluating left ventricular function.
Rationale for incorrect answers:
A. To the right of the aorta. This is in the right upper sternal border, typically used to auscultate the aortic valve area. It is not associated with the PMI or apex of the heart.
B. At left atrium: This is positioned more posteriorly in the chest and not palpable or auscultated directly from the anterior chest wall.
C. Placed slightly below 2: Still in the left parasternal area, likely over the pulmonic or tricuspid area, but not the apex.
D. Placed slightly below 3: This is near the left lower sternal border, where tricuspid sounds may be heard, but it's still not the apex.
F. At xiphoid process: This is the epigastric area, well below the heart’s apex, and is not used to assess apical pulse or PMI.
Take-home points:
- The PMI is best auscultated at the 5th intercostal space, midclavicular line, which corresponds to point 5 in the diagram.
- Accurate location of the PMI is essential in assessing left ventricular function and detecting cardiac enlargement or displacement.
Correct Answer is B
Explanation
When multiple abnormal readings are present, the nurse must prioritize interventions based on the urgency, potential for deterioration, and underlying cause. The principle of ABC (Airway, Breathing, Circulation), followed by temperature regulation and pain control, guides prioritization.
Rationale for correct answer:
B. Heart rate 130 beats/min, apical: A heart rate of 130 bpm is significantly elevated and may indicate compensatory response to fever, pain, dehydration, or underlying cardiac stress.
Rationale for incorrect answers:
A. Temperature 10B.4°F (39.1°C): This is a moderate to high-grade fever, likely contributing to the elevated HR and RR. The fever itself is not immediately life-threatening, but needs to be addressed with antipyretics.
C. Respiratory rate 25 breaths/min: Mild tachypnea may be a response to fever, pain, or anxiety, but could also signal early respiratory distress. Although not critically high, this rate warrants ongoing respiratory assessment.
D. BP 145/80: This is a mildly elevated systolic BP, possibly related to stress, fever, or pain. It is not immediately concerning in this clinical context
Take-home points:
- Always prioritize circulation and respiratory compromise first - HR and RR abnormalities can indicate early deterioration.
- Fever and elevated BP are important, but unless critical, they typically follow cardiac and respiratory concerns in priority.
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