When auscultating the blood pressure of a 25-year-old, the nurse hears the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg the Korotkoff sounds muffle. At 92 mm Hg the Korotkoff sounds disappear. How should the nurse record this patient's blood pressure?

200/92

100/200/92

200/100

200/100/92

Answer and Explanation

The Correct Answer is D

A. 200/92. This format does not include the muffling point (Phase IV), which is important in some clinical settings, such as in critically ill patients or those with vascular diseases.
B. 100/200/92. This order is incorrect because the systolic pressure should always be listed first, followed by the diastolic components.
C. 200/100. This format omits the point at which sounds completely disappear (Phase V), which is the true diastolic pressure in most cases. However, in some individuals, particularly those with conditions like aortic regurgitation, the muffling point may be recorded as an additional reading.
D. 200/100/92. The correct way to document blood pressure when Korotkoff sounds muffle before disappearing is to include all three values: the systolic pressure (Phase I), the point of muffling (Phase IV), and the diastolic pressure (Phase V). This ensures a complete and accurate blood pressure recording.

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Correct Answer is ["A","B","C","E"]

Explanation

A. Distractions such as music. Music and other distractions, such as guided imagery or television, can help shift the patient's focus away from pain, reducing discomfort and anxiety.
B. Massage. Gentle massage can help promote relaxation, improve circulation, and reduce muscle tension, which may enhance pain relief when used alongside medication.
C. Cold or heat applications. Cold therapy can help reduce inflammation and swelling, while heat therapy can improve blood flow and relax muscles, making them effective in managing arthritis pain and post-surgical discomfort.
D. Vigorous rubbing of the joints. Vigorous rubbing could worsen pain and cause irritation, particularly in a patient with arthritis and post-surgical pain. Gentle approaches are more appropriate.
E. Relaxation techniques. Deep breathing, guided imagery, and progressive muscle relaxation can help lower stress and enhance the body's ability to manage pain.

Correct Answer is ["2500"]

Explanation

Calculation:

To convert liters (L) to milliliters (mL), the conversion factor is:

1L = 1000mL

Given:

(2.5L×1000mL)/ 1L

= 2500mL

Thus, 2.5 L = 2500 mL.

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When auscultating the blood pressure of a 25-year-old, the nurse hears the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg the Korotkoff sounds muffle. At 92 mm Hg the Korotkoff sounds disappear. How should the nurse record this patient's blood pressure?

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Naxlex Comprehensive Predictor Exams

Exhibits Lana is developing Mrs. Watson's care plan. She wants to add more interventions and not just deliver pain medication. What are some other nursing actions that would be helpful to Mrs. Watson? Select the 4 correct answers (Case Study #2)

Correct Answer is ["A","B","C","E"]

Explanation

2.5 L=

Correct Answer is ["2500"]

Explanation

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