Take full exam for free

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?

Release the manometer valve immediately.

Document the absence of the radial pulse.

Inflate the blood pressure cuff to 120 mm Hg.

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.

Free Nursing Test Bank

Take full exam free

View Related questions

A. Begin with querry that are less sensitive in nature. B. Get the most difficult querry over with first. C. Share personal values to put the client at ease. D. Ask querry in a vague, non-specific format. E. Ask querry in a vague, non-specific format.

Correct Answer is A

Explanation

Choice A rationale

Beginning with questions that are less sensitive in nature helps build rapport and makes the client more comfortable. This approach gradually leads to more sensitive topics, reducing anxiety and promoting honest responses.

Choice B rationale

Getting the most difficult questions over with first can increase the client’s anxiety and discomfort, leading to less honest or incomplete answers. It is not an effective strategy for sensitive topics.

Choice C rationale

Sharing personal values to put the client at ease can introduce bias and affect the client’s responses. It is important to remain neutral and nonjudgmental.

Choice D rationale

Asking questions in a vague, non-specific format can lead to misunderstandings and incomplete information. Clear, direct questions are more effective for gathering accurate information.

A. Inject in the abdominal area at least 2 inches (5.1 cm) from the umbilicus. B. Rotate injections between the abdomen and gluteal areas. C. Massage the injection site to increase absorption. D. Expel the air in the prefilled syringe prior to injection.

Correct Answer is A

Explanation

Choice A rationale

Injecting in the abdominal area at least 2 inches (5.1 cm) from the umbilicus is the correct technique for subcutaneous heparin injections. This reduces the risk of injury to blood vessels and nerves and ensures consistent absorption of the medication.

Choice B rationale

Rotating injections between the abdomen and gluteal areas is not recommended for low molecular weight heparin (LMWH) injections. The abdomen is the preferred site for consistent absorption.

Choice C rationale

Massaging the injection site to increase absorption is not recommended for LMWH injections. Massaging can cause bruising and affect the absorption of the medication.

Choice D rationale

Expelling the air in the prefilled syringe prior to injection is not recommended for LMWH injections. The air bubble helps ensure the entire dose is administered and prevents medication from leaking out.

Take full exam for free

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?

Free Nursing Test Bank

Correct Answer is A

Explanation

Correct Answer is A

Explanation

Quick Links

Resources

Take full exam for free 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?

Free Nursing Test Bank

The nurse is interviewing a client with lower abdominal pain and dysuria, and needs to the client about sexual activity. Which approach is best for the nurse to use?

Correct Answer is A

Explanation

The nurse is teaching the client to self-administer a dose of low molecular weight heparin SUBQ. Which instruction should the nurse include?

Correct Answer is A

Explanation

An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep. What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.

The nurse is teaching a client about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?

The nurse observes a practical nurse (PN) performing oral care on an unconscious client. Which action by the PN indicates to the nurse the need for additional training?

When providing health teaching to older adult clients, which action is most important for the nurse to implement?

The nurse notices a client grimacing while moving from the bed to a chair, but when asked about the pain the client denies having any pain. Which intervention should the nurse implement first?

When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?

A client with a family history of cardiac disease is seeking information to control risk factors. Which lifestyle modification is most important for the nurse to encourage?

The nurse enters a client’s room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

Quick Links

Resources

Take full exam for free

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?