The practical nurse (PN) is assessing a client's blood pressure using a manual sphygmomanometer on the left arm. In which sequence should the PN implement these actions? (Arrange from first action on top to last on the bottom.)
Release air from the cuff slowly.
Position the blood pressure cuff.
Pump the cuff while palpating the pulse.
Listen for the systolic pressure reading.
Listen for the diastolic pressure reading.
The Correct Answer is B,C,A,D,E
A. Release air from the cuff slowly: Air is released gradually (2–3 mmHg per second) to allow accurate identification of Korotkoff sounds while preventing false readings.
B. Position the blood pressure cuff: The PN first places the cuff snugly around the upper arm, ensuring it is at heart level and the artery marker aligns with the brachial artery for accurate measurement.
C. Pump the cuff while palpating the pulse: The PN inflates the cuff until the radial pulse disappears to estimate systolic pressure, helping determine how high to inflate when taking the actual reading.
D. Listen for the systolic pressure reading: The first clear tapping sound heard through the stethoscope indicates the systolic blood pressure — the pressure during ventricular contraction.
E. Listen for the diastolic pressure reading: The disappearance of the sounds marks the diastolic pressure, representing the pressure during ventricular relaxation, which is recorded as the lower number in the BP reading.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Feed the infant when he cries: Crying increases oxygen demand and energy expenditure, which can be risky for an infant with heart failure. Feeding during distress may exacerbate fatigue and respiratory compromise.
B. Allow infant to rest before feeding: Allowing the infant to rest conserves energy and reduces cardiac workload. Adequate rest before feeding helps the infant tolerate oral intake without becoming fatigued, supporting better nutritional intake and growth.
C. Weigh before and after feeding: While weighing can help assess intake, it is not a primary intervention for managing feeding in an infant with heart failure. The focus should first be on energy conservation and safe feeding practices.
D. Insert a nasogastric feeding tube: NG tube feeding is reserved for infants unable to take sufficient oral intake safely. If the infant can feed orally with appropriate rest, NG feeding is unnecessary and more invasive.
Correct Answer is C
Explanation
A. Hemoglobin and Hematocrit: These values reflect red blood cell status and oxygen-carrying capacity but do not provide information about kidney function. They are not directly relevant to assessing risk for nephrotoxicity before antibiotic administration.
B. Serum calcium: Calcium levels indicate electrolyte and bone metabolism status but do not assess renal function. Monitoring calcium is unrelated to the risk of nephrotoxic effects from antibiotics.
C. Serum creatinine: Serum creatinine is a key indicator of kidney function and glomerular filtration. Reviewing this value helps the PN determine if the client’s kidneys can safely handle nephrotoxic antibiotics and guides dosing decisions to prevent further renal injury.
D. White blood cell count (WBC): WBC indicates immune response and infection status but does not assess renal function. While important for infection monitoring, it does not inform nephrotoxicity risk.
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