Various sounds are heard when assessing a blood pressure. What does the second sound heard through the stethoscope represent?
Systolic pressure
Pulse pressure
Auscultatory gap
Diastolic pressure
The Correct Answer is D
A. Systolic pressure:
The first sound heard during blood pressure measurement corresponds to the systolic pressure, the pressure in the arteries when the heart is contracting.
B. Pulse pressure:
Pulse pressure is the numerical difference between the systolic and diastolic pressures but is not specifically represented by a sound in blood pressure measurement.
C. Auscultatory gap:
An auscultatory gap is a temporary disappearance of sounds during blood pressure measurement, typically occurring between the systolic and diastolic pressures. It is not directly associated with the second sound.
D. Diastolic pressure:
The second sound heard corresponds to the closure of the aortic valve, marking the beginning of diastole. This sound represents the diastolic pressure, which is the pressure in the arteries when the heart is at rest.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Every four hours:
Turning a client every four hours may not be frequent enough to prevent pressure ulcers, especially in individuals with physical limitations or recent surgical procedures.
B. Every hour:
Turning a client every hour might be too frequent for some patients, and it may disrupt their rest and sleep. The optimal frequency depends on the client's condition.
C. Every shift:
Turning a client every shift (which typically spans 8-12 hours) may not provide adequate prevention for pressure ulcers, especially if the client has limited mobility.
D. Every two hours:
Turning a client every two hours is a common practice to prevent pressure ulcers. This interval helps redistribute pressure on vulnerable areas, improving blood circulation and reducing the risk of skin breakdown.
Correct Answer is C
Explanation
A. Pulse:
A pulse rate of 88 bpm is within the normal range. While it's important to monitor the pulse for changes, the reported pulse rate does not raise immediate concerns.
B. Temperature:
An oral temperature of 99.2 degrees Fahrenheit is within the normal range. While it's slightly elevated, it might be influenced by various factors, and isolated temperature readings are not as urgent as other vital signs.
C. Blood Pressure:
A blood pressure reading of 178/112 mm Hg is significantly elevated. High blood pressure is a major concern due to the potential risks it poses to the cardiovascular system, kidneys, and other organs. Immediate attention and further assessment are needed.
D. Respirations:
Respiratory rate of 18 bpm is within the normal range. While it's important to monitor respiratory rate, the reported rate does not raise immediate concerns.
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