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 B
Explanation
A. Kussmaul's respirations are rapid, deep, and labored breaths often seen in metabolic acidosis, which does not match the pattern described.
B. Cheyne-Stokes respirations are characterized by a pattern of deep and fast breathing followed by periods of apnea. This pattern is seen in patients with severe conditions like heart failure or brain injury.
C. Biot's respirations are irregular, but the cycle does not have a distinct pattern of fast, slow, and apnea periods.
D. Hyperventilation refers to an increased rate of breathing but does not involve the cycles of deep, slow, and apneic phases characteristic of Cheyne-Stokes.
Correct Answer is D
Explanation
A. A murmur or swishing sound does not correspond to the diastolic pressure; it is more indicative of turbulent blood flow.
B. Clear tapping sounds are heard at systolic pressure but do not indicate diastolic pressure.
C. Knocking sounds are associated with systolic pressure, not diastolic.
D. The muffling sound heard after the first Korotkoff sounds indicates the diastolic pressure in children and some adults, which is the correct method for assessing the diastolic reading.
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