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 A

Explanation

Choice A rationale

Beginning with questions that are less sensitive in nature helps build rapport and makes the client more comfortable. This approach gradually leads to more sensitive topics, reducing anxiety and promoting honest responses.

Choice B rationale

Getting the most difficult questions over with first can increase the client’s anxiety and discomfort, leading to less honest or incomplete answers. It is not an effective strategy for sensitive topics.

Choice C rationale

Sharing personal values to put the client at ease can introduce bias and affect the client’s responses. It is important to remain neutral and nonjudgmental.

Choice D rationale

Asking questions in a vague, non-specific format can lead to misunderstandings and incomplete information. Clear, direct questions are more effective for gathering accurate information.

A. “It’s important to dress the right arm first.”. B. “We will give you a class on dressing tomorrow.”. C. “Dressing must be a frustrating experience for you.”. D. “This unit has a policy against staff harassment.”.

Correct Answer is C

Explanation

Choice A rationale

Telling the client to dress the right arm first is practical advice but does not address the client’s frustration and emotional state. It is important to acknowledge the client’s feelings to provide empathetic care.

Choice B rationale

Offering a class on dressing tomorrow does not address the immediate frustration and emotional response of the client. The client needs support and understanding in the moment.

Choice C rationale

Acknowledging that dressing must be a frustrating experience for the client shows empathy and understanding. It validates the client’s feelings and helps build a therapeutic relationship.

Choice D rationale

Mentioning a policy against staff harassment is inappropriate and does not address the client’s frustration. It may escalate the situation and damage the nurse-client relationship.

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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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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?