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?

Release the manometer valve immediately.

Document the absence of the radial pulse.

Inflate the blood pressure cuff to 120 mm Hg.

Record a palpable systolic pressure of 90 mm Hg. .

Answer and Explanation

The Correct Answer is C

Choice A rationale

Releasing the manometer valve immediately is not appropriate as it does not allow for an accurate measurement of systolic blood pressure.

Choice B rationale

Documenting the absence of the radial pulse is not the correct action. The nurse needs to continue the procedure to obtain an accurate systolic blood pressure reading.

Choice C rationale

Inflating the blood pressure cuff to 120 mm Hg is the correct action. The nurse should inflate the cuff 30 mm Hg above the point where the radial pulse is no longer palpable to ensure an accurate measurement.

Choice D rationale

Recording a palpable systolic pressure of 90 mm Hg is incorrect. The nurse needs to inflate the cuff further to obtain an accurate systolic blood pressure reading

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Correct Answer is D

Explanation

Choice A rationale

Positioning the head with the chin tilted slightly downward is an appropriate action when feeding a client with a CVA. This position helps prevent aspiration by closing the airway and directing food away from the trachea.

Choice B rationale

Allowing 30 minutes of rest before feeding is an appropriate action. Resting before feeding can help improve digestion and reduce the risk of aspiration by ensuring the client is alert and responsive during feeding.

Choice C rationale

Placing food on the unaffected side of the mouth is an appropriate action when feeding a client with a CVA. This technique helps the client manage food more effectively and reduces the risk of aspiration.

Choice D rationale

Raising the head of the bed to 60 degrees is not sufficient to prevent aspiration. The head of the bed should be elevated 45 to 90 degrees to ensure proper positioning and reduce the risk of aspiration. Therefore, if the UAP raises the head of the bed to only 60 degrees, it indicates the need for additional teaching.

A. Review the pain medications prescribed. B. Monitor the client’s nonverbal behavior. C. Administer PRN oral pain medication. D. Ask the client what is causing the grimacing. E. Ask the client what is causing the grimacing.

Correct Answer is D

Explanation

Choice A rationale

Administering PRN oral pain medication without further assessment may not be appropriate, as the client’s pain needs must be fully evaluated before intervening with medication. Pain medication should be administered based on an accurate assessment rather than solely on nonverbal cues.

Choice B rationale

Reviewing the pain medications prescribed is important, particularly if the client is exhibiting signs of uncontrolled pain. However, this intervention should be secondary to further assessment of the client’s current pain status.

Choice C rationale

Choice D rationale

Asking the client what is causing the grimacing is the correct intervention to implement first. Nonverbal cues, such as grimacing, can indicate the presence of pain, even if the client denies it verbally. By closely monitoring the client’s nonverbal behavior, the nurse can gather additional information about the client’s pain experience and make appropriate interventions based on a comprehensive assessment.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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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?