Nokea
When auscultating the blood pressure of a 25-year-old patient, the nurse notices that 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?
- A. 200/92
- B. 200/100
- C. 100/200/92
- D. 200/100/92
Correct Answer: A
Rationale: When auscultating blood pressure, it is crucial to note the points at which Korotkoff sounds change. In adults, the last audible sound indicates the diastolic pressure. In this case, the Korotkoff sounds muffle at 100 mm Hg and disappear at 92 mm Hg. Therefore, the blood pressure should be recorded as systolic/diastolic, which is 200/92. Choices B, C, and D are incorrect because they do not reflect the correct points where the Korotkoff sounds change during blood pressure measurement.
You may also like to solve these questions
Why should a palpated pressure be performed before auscultating blood pressure?
- A. To more clearly hear the Korotkoff sounds.
- B. To detect the presence of an auscultatory gap.
- C. To avoid missing a falsely elevated blood pressure.
- D. To more readily identify phase IV of the Korotkoff sounds.
Correct Answer: B
Rationale: Performing a palpated pressure before auscultating blood pressure helps in detecting the presence of an auscultatory gap. An auscultatory gap is a period during blood pressure measurement when Korotkoff sounds temporarily disappear before reappearing. Inflation of the cuff 20 to 30 mm Hg beyond the point where a palpated pulse disappears helps in identifying this gap. This technique ensures accurate blood pressure measurement by preventing the underestimation of blood pressure values. The other options are incorrect because palpating the pressure is not primarily done to hear Korotkoff sounds more clearly, avoid missing falsely elevated blood pressure, or readily identify a specific phase of Korotkoff sounds.
Which technique is correct when assessing the radial pulse of a patient?
- A. Palpate for 1 minute if the rhythm is irregular.
- B. Palpate for 15 seconds and multiply by 4 if the rhythm is regular.
- C. Palpate for 2 full minutes to detect any variation in amplitude.
- D. Palpate for 10 seconds and multiply by 6 if the rhythm is regular and the patient has no history of cardiac abnormalities.
Correct Answer: A
Rationale: When assessing the radial pulse, if the rhythm is irregular, the pulse should be counted for a full minute to get an accurate representation of the pulse rate. In cases where the rhythm is regular, the recommended technique is to palpate for 15 seconds and then multiply by 4 to calculate the beats per minute. This method is more accurate and efficient for normal or rapid heart rates. Palpating for 30 seconds and multiplying by 2 is not as effective, as any error in counting results in a larger discrepancy in the calculated heart rate. Palpating for 2 full minutes is excessive and not necessary for routine pulse assessment. Palpating for 10 seconds and multiplying by 6 is not a standard technique and may lead to inaccuracies, especially in patients with cardiac abnormalities.
When preparing a patient on complete bed rest to eat, at what degree angle or more should you put the head of the bed up?
- A. 10
- B. 15
- C. 20
- D. 30
Correct Answer: D
Rationale: The correct answer is D: 30. When a patient is on complete bed rest, it is essential to elevate the head of the bed at a 30-degree angle or more before meals. This position helps prevent choking and aspiration of food during eating by promoting proper swallowing and digestion. Choices A, B, and C are incorrect because they do not provide the optimal elevation needed to support safe and effective feeding for a patient on complete bed rest.
In a patient with acromegaly, which assessment finding will the nurse expect to find?
- A. Sternal deformity and hyperextensible joints
- B. Growth retardation and a delayed onset of puberty
- C. Overgrowth of bone in the face, head, hands, and feet
- D. Increased height and weight and delayed sexual development
Correct Answer: C
Rationale: Acromegaly is a condition characterized by excessive secretion of growth hormone in adulthood after normal body growth completion. This hormonal excess leads to overgrowth of bones in the face, head, hands, and feet; however, there is no significant change in height. Stating sternal deformity and hyperextensible joints is incorrect as they are characteristic findings of Marfan syndrome. Growth retardation and delayed onset of puberty are not typical of acromegaly but are seen in hypopituitary dwarfism. Increased height, weight, and delayed sexual development are features of gigantism, not acromegaly. Therefore, the correct assessment finding in a patient with acromegaly would be overgrowth of bone in the face, head, hands, and feet.
A new staff nurse completes orientation to the psychiatric unit. This nurse will expect to ask an advanced practice nurse to perform which action for patients?
- A. Perform mental health assessment interviews
- B. Establish therapeutic relationships
- C. Prescribe psychotropic medications
- D. Individualize nursing care plans
Correct Answer: C
Rationale: Prescriptive privileges are granted to Master's-prepared nurse practitioners who have taken special courses on prescribing medications. The nurse prepared at the basic level performs mental health assessments, establishes relationships, and provides individualized care planning. In this scenario, the new staff nurse would ask the advanced practice nurse to prescribe psychotropic medications, as this is within their scope of practice and expertise. Establishing therapeutic relationships, performing mental health assessments, and individualizing care plans are typically responsibilities of staff nurses at the basic level, not advanced practice nurses.