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The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?

A.

Release the manometer valve immediately.

B.

Document the absence of the radial pulse.

C.

Inflate the blood pressure cuff to 120 mm Hg.

D.

Record a palpable systolic pressure of 90 mm Hg.

Answer and Explanation

The Correct Answer is C

Choice A rationale

 

Releasing the manometer valve immediately is not appropriate as it does not allow for an accurate measurement of systolic blood pressure.

 

Choice B rationale

 

Documenting the absence of the radial pulse is not the correct action. The nurse needs to continue the procedure to obtain an accurate systolic blood pressure reading.

 

Choice C rationale

 

Inflating the blood pressure cuff to 120 mm Hg is the correct action. The nurse should inflate the cuff 30 mm Hg above the point where the radial pulse is no longer palpable to ensure an accurate measurement.

 

Choice D rationale

 

Recording a palpable systolic pressure of 90 mm Hg is incorrect. The nurse needs to inflate the cuff further to obtain an accurate systolic blood pressure reading. 


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View Related questions

Correct Answer is D

Explanation

Choice A rationale

Providing a back rub at bedtime can help promote relaxation and improve sleep quality. However, it does not directly address the issue of wandering, which poses a safety risk for the client. The primary concern should be ensuring the client’s safety by preventing wandering.

Choice B rationale

Applying wrist restraints to prevent wandering is not an appropriate first intervention. Restraints should be used as a last resort when other measures have failed, and they can cause physical and psychological harm to the client. The focus should be on non-restrictive interventions to ensure safety.

Choice C rationale

Administering a PRN sedative prescription may help the client sleep, but it should not be the first intervention. Sedatives can have side effects and may not address the underlying cause of the client’s wandering. Non-pharmacological interventions should be tried first.

Choice D rationale

Leaving the door to the client’s room open slightly allows the client to see and hear staff members as they pass by, which can help reduce feelings of isolation and anxiety. This intervention addresses both the client’s sleep issues and wandering behavior by providing a sense of security and supervision.

Correct Answer is A

Explanation

Choice A rationale

Smoking cessation is the most important lifestyle modification for preventing and managing cardiac disease. Smoking is a major modifiable risk factor that can cause atherosclerosis, hypertension, arrhythmias, thrombosis, and myocardial infarction. Quitting smoking has a more direct effect on improving the function and structure of the blood vessels and heart, significantly reducing the risk of cardiovascular events and mortality.

Choice B rationale

A low-fat diet is a useful lifestyle modification for preventing and managing cardiac disease, but it is not the most important one. While it helps in lowering cholesterol levels and reducing inflammation, smoking cessation has a stronger influence on overall cardiovascular health.

Choice C rationale

Stress reduction is a helpful lifestyle modification for preventing and managing cardiac disease, but it is not the most important one. Although managing stress can improve heart health, smoking cessation has a more immediate and significant impact on reducing cardiovascular risks.

Choice D rationale

Regular exercise is beneficial for preventing and managing cardiac disease, but it is not the most important lifestyle modification. Exercise helps in maintaining a healthy weight, lowering blood pressure, and improving overall cardiovascular health, but smoking cessation has a greater impact on reducing the risk of cardiovascular events.

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