If a patient's blood pressure measures 146/92 on the left arm and 138/84 on the right arm, what would you do?
Wait 30 minutes and take the pressures again.
Record both pressures in the medical record.
Retake the pressure on both arms.
Retake the pressure on the left arm.
The Correct Answer is C
A. Waiting 30 minutes is unnecessary unless there is concern about an acute change in the patient's condition.
B. While both readings can be recorded, the difference between arms should be noted, as it can indicate underlying issues such as vascular problems.
C. It is important to retake the blood pressure on both arms to verify accuracy and check for any significant discrepancy.
D. Retaking the pressure on just one arm may miss important information about the other arm's readings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Tapping is the first Korotkoff sound and corresponds to the systolic pressure, not the diastolic pressure.
B. Knocking does not describe any Korotkoff sound associated with the blood pressure reading.
C. Silence is typically noted after the muffling sound and indicates the cessation of Korotkoff sounds, which can be used to assess diastolic pressure in adults, but it is not used in children.
D. The muffling sound occurs before the disappearance of Korotkoff sounds and is often used to mark the diastolic pressure in both children and some adults, making it the correct answer.
Correct Answer is A
Explanation
A. Pushing the soles of the feet against the nurse's hands is a standard test to assess the strength of the lower extremities. It provides a clear indication of muscular strength and motor function.
B. Wiggling toes helps assess for sensation but does not evaluate overall strength or motor function in the lower extremities.
C. Pulling both feet up to stretch the Achilles tendons is not an appropriate method for assessing lower extremity strength.
D. Standing independently does not evaluate strength comprehensively and is more related to balance and coordination.
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