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. It acknowledges the client's emotions by expressing empathy ("I am sad for you") and offering support ("I'll stay with you for a while if you need to talk"). This approach validates the client's grief, acknowledges the significance of their loss, and offers the opportunity for the client to express their feelings if they choose to do so.
A. This can inadvertently minimize the client's grief by suggesting that the nurse's losses are comparable or that the nurse understands the client's emotions completely.
B. It does not acknowledge or validate the client's current emotions and may overlook the complex feelings associated with losing a parent.
C. This response, although intended to provide encouragement, may not be therapeutic in the context of immediate grief. It suggests a future positive outcome from the loss without acknowledging the client's current emotional pain.
Correct Answer is D
Explanation
D. Metabolic alkalosis is characterized by an increased pH (alkalosis) and an increased HCO3. In this case, the pH is elevated (7.5), indicating alkalosis, which supports metabolic alkalosis. The HCO3 is elevated at 40 mEq/L, which further supports metabolic alkalosis. The PaCO2 is normal or slightly low (36 mmHg), which can occur as a compensatory response to metabolic alkalosis.
A. Respiratory alkalosis is characterized by an increase in pH (alkalosis) and a decrease in PaCO2 (hypocapnia). In this scenario, the pH is elevated (7.5), which indicates alkalosis. The PaCO2 is 36 mmHg, which is within the normal range (35-45 mmHg) but slightly on the lower side (slight hypocapnia). The HCO3 is elevated at 40 mEq/L, which suggests a compensatory response by the kidneys to retain bicarbonate to counteract the alkalosis.
B. Respiratory acidosis is characterized by a decrease in pH (acidosis) and an increase in PaCO2 (hypercapnia). In this case, the pH is elevated (7.5), indicating alkalosis, which contradicts respiratory acidosis. The PaCO2 is 36 mmHg, which is normal or slightly low, not high as expected in respiratory acidosis. The elevated HCO3 (40 mEq/L) suggests a compensatory metabolic response to the alkalosis, not to acidosis.
C. Metabolic acidosis is characterized by a decreased pH (acidosis) and a decreased HCO3. In this scenario, the pH is elevated (7.5), indicating alkalosis, which contradicts metabolic acidosis. The HCO3 is elevated at 40 mEq/L, indicating metabolic alkalosis rather than metabolic acidosis.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today