The nurse is obtaining a systolic blood pressure by palpation.

While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?

Record a palpable systolic pressure of 90 mm Hg.

Release the manometer valve immediately.

Document the absence of the radial pulse.

Inflate the blood pressure cuff to 120 mm Hg.

Answer and Explanation

The Correct Answer is D

Choice A rationale
Recording a palpable systolic pressure of 90 mm Hg without further action would likely underestimate the true systolic pressure. The nurse should inflate the cuff to a higher pressure to obtain an accurate measurement.
Choice B rationale
Releasing the manometer valve immediately would lead to deflating the cuff and potentially missing the opportunity to obtain an accurate blood pressure measurement.
Choice C rationale
Documenting the absence of the radial pulse is important, but it is also crucial to ensure that blood pressure measurements are obtained correctly. Further action is needed to obtain an accurate measurement.
Choice D rationale
Inflating the blood pressure cuff to 120 mm Hg is the correct action. When the radial pulse becomes unpalpable during cuff inflation, the cuff should be inflated to a higher pressure (usually 20-30 mm Hg above the point where the radial pulse disappears) and then slowly deflated while palpating for the return of the radial pulse.

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Correct Answer is A

Explanation

Choice A rationale
Beginning with queries that are less sensitive in nature can help establish rapport and trust with the client. This approach makes the client more comfortable and willing to disclose personal information, including details about sexual activity.
Choice B rationale
Asking queries in a vague, non-specific format may lead to confusion and incomplete information. It is important to ask clear and direct questions to obtain accurate information.
Choice C rationale
Getting the most difficult queries over with first may cause the client to feel uncomfortable and defensive, making it harder to obtain accurate information.
Choice D rationale
Sharing personal values to put the client at ease is not appropriate in a professional setting. The nurse should maintain a neutral and non-judgmental approach to encourage open communication.

A. Have the client demonstrate prescribed wound care. B. After each instruction, ask if the client understands. C. Have an interpreter repeat the wound care instructions. D. Provide written instructions in the client’s native language.

Correct Answer is A

Explanation

Choice A rationale
Having the client demonstrate prescribed wound care is the most effective method to evaluate the client’s understanding of self-care at home. This approach allows the nurse to directly observe the client’s ability to perform the necessary tasks and provide immediate feedback and clarification as needed. Demonstration ensures that the client can correctly follow the wound care instructions, which is crucial for proper healing and preventing complications.
Choice B rationale
Asking the client if they understand after each instruction may not be effective, especially if the client is not comfortable expressing confusion or misunderstanding. This method relies on the client’s verbal confirmation, which may not accurately reflect their ability to perform the wound care tasks correctly.
Choice C rationale
Having an interpreter repeat the wound care instructions can help bridge the language barrier, but it does not allow for direct observation of the client’s ability to perform the necessary tasks. While the interpreter can ensure that the client understands the instructions, it does not provide the nurse with a way to assess the client’s practical skills.
Choice D rationale
Providing written instructions in the client’s native language can be helpful, but it does not allow the nurse to directly evaluate the client’s understanding and ability to perform the wound care tasks. Written instructions alone may not be sufficient for clients who have limited literacy or who may have difficulty following written directions.

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The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?

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The nurse is obtaining a systolic blood pressure by palpation.

While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?