Nokea
When taking a client's blood pressure, the healthcare professional is unable to distinguish the point at which the first sound was heard. What is the best action for the healthcare professional to take?
- A. Deflate the cuff completely and immediately reattempt the reading.
- B. Reinflate the cuff completely and leave it inflated for 90 to 110 seconds before taking the second reading.
- C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading.
- D. Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen.
Correct Answer: C
Rationale: The correct action when unable to distinguish the point of the first sound during blood pressure measurement is to deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. This allows blood flow to return to the extremity, ensuring a more accurate reading the second time. It is important to ensure that the cuff is fully deflated and the appropriate wait time is given to obtain an accurate blood pressure measurement.
You may also like to solve these questions
What is the most effective way to implement a teaching plan?
- A. Teach the information that the learner wants to learn first.
- B. Streamline the teaching plan to include only essential information.
- C. Present to the learner all the necessary information to meet the objectives.
- D. Provide the learner with written material to review before teaching sessions.
Correct Answer: A
Rationale: The most effective way to implement a teaching plan is to teach the information that the learner wants to learn first. Teaching should be learner-centered, responding to the individual's needs and preferences. Learning is most successful when it addresses the specific interests and goals of the learner, as it increases motivation and engagement. By starting with what the learner is interested in, you can create a more effective and engaging learning experience.
A client is receiving intravenous (IV) fluids postoperatively. Which assessment finding should prompt the nurse to stop the infusion and notify the healthcare provider?
- A. The client reports pain at the IV site
- B. The client's blood pressure is elevated
- C. The client has swelling at the IV site
- D. The client's heart rate is irregular
Correct Answer: C
Rationale: Swelling at the IV site may indicate infiltration or phlebitis, which requires stopping the IV infusion and notifying the healthcare provider. Infiltration occurs when the IV fluid leaks into the surrounding tissue, causing swelling and potential damage. It is crucial to act promptly to prevent further complications and ensure the client's safety.
How should the nurse prepare the body of a deceased adult for transfer to the mortuary?
- A. Leave the body as is, no preparation needed
- B. Bathe the body and place ID tags on it
- C. Remove dentures before bathing the body
- D. Position the body with its head down and arms folded on its chest
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The daughter of an older woman who became depressed following the death of her husband asks, 'My mother was always well-adjusted until my father died. Will she tend to be sick from now on?' Which response is best for the nurse to provide?
- A. She is almost sure to be less able to adapt than before.
- B. It's highly likely that she will recover and return to her pre-illness state.
- C. If you can interest her in something besides religion, it will help her stay well.
- D. Cultural strains contribute to each woman's tendencies for recurrences of depression.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The client is being taught about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?
- A. Remove needle before discarding used syringes
- B. Wear gloves to dispose of the needle and syringe
- C. Don a face mask before administering the medication
- D. Wash hands before handling the needle and syringe
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.