The nurse, while obtaining the blood pressure reading of a client, is uncertain when the muffled sounds have ended. What is the nurse's best action at this time?
pump the cuff up again immediately before releasing it.
use the client's radial pulse to determine how high to pump up the cuff
obtain another cuff and take the blood pressure again in 30 minutes.
release the cuff completely and wait two minutes before retaking the blood pressure.
The Correct Answer is D
D. When uncertain about the endpoint of Korotkoff sounds, releasing the cuff completely allows the blood flow to return to normal in the arm. After waiting for about two minutes, the nurse can reinflate the cuff and begin the measurement process again. This approach helps ensure accurate measurement by resetting conditions and allowing for a clearer determination of when Korotkoff sounds start and stop.
A. This option is not recommended because re-inflating the cuff immediately could lead to incorrect readings due to inaccurate pressure settings or discomfort for the client. It does not address the issue of determining the endpoint of the Korotkoff sounds.
B. This technique involves palpating the radial pulse while inflating the cuff and then inflating the cuff until the pulse is no longer palpable. This method can help ensure the cuff is inflated to an appropriate pressure level, which is typically about 30 mmHg above the point where the radial pulse disappears.
However, this option does not directly address the uncertainty about when to listen for the Korotkoff sounds to stop.
C. This option is not practical for addressing the immediate uncertainty during the current blood pressure measurement. Waiting 30 minutes to retake the blood pressure with a different cuff may delay necessary assessment and intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. This statement exemplifies the ethical principle of fidelity, also known as faithfulness or commitment. Fidelity involves keeping promises, being reliable, and fulfilling commitments made to patients. By returning promptly with the pain medication as promised, the nurse demonstrates fidelity by honoring their commitment to the patient's care and comfort.
A. This statement reflects the ethical principle of justice, which emphasizes fairness and equality in treatment for all patients. Justice ensures that resources and treatments are distributed fairly among individuals.
B This statement demonstrates the ethical principle of nonmaleficence, which focuses on preventing harm and minimizing risks to patients. It emphasizes the nurse's commitment to avoiding harm or injury to the patient.
C. This statement relates to truth-telling or veracity, which involves providing honest and accurate information to patients about their care, procedures, and potential outcomes. It reflects transparency and respect for patient autonomy.
Correct Answer is B
Explanation
B Leaning away from the client can convey disinterest, distraction, or a lack of engagement. It creates physical distance and may inhibit the client from feeling heard or valued. Thus, leaning away from the client can be a barrier to active listening as it diminishes the nurse's ability to fully attend to and understand the client's message.
A. An open posture, where the nurse's body is facing the client with arms uncrossed and relaxed, signals openness and receptivity. It encourages communication and shows the client that the nurse is engaged and attentive. Therefore, an open posture promotes active listening rather than serving as a barrier.
C. Eye contact is essential for effective communication and active listening. It demonstrates attentiveness, interest, and respect. Establishing eye contact helps the nurse to connect with the client and encourages them to continue sharing their thoughts and feelings. Therefore, eye contact supports active listening rather than hindering it.
D. Sitting squarely facing the client promotes engagement and shows that the nurse is focused on the client. It facilitates direct communication and helps the nurse to observe the client's nonverbal cues effectively. This posture encourages open dialogue and supports active listening rather than acting as a barrier.
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