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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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Correct Answer is B

Explanation

Choice A rationale

Initiating a fall risk protocol is not necessary when the client demonstrates an upright posture and a smooth, steady gait. Fall risk protocols are typically initiated when there are signs of instability or a history of falls.

Choice B rationale

Recording the client’s ability to perform ADLs safely is the appropriate action. This documentation provides a baseline for the client’s functional status and helps in planning further care. It also ensures that the client’s current abilities are noted for future reference.

Choice C rationale

Determining the client’s activity tolerance is important but not the immediate next step after observing a smooth and steady gait. This assessment can be done later to evaluate the client’s endurance and capacity for physical activities.

Choice D rationale

Teaching the client to shorten the stride to prevent falls is unnecessary when the client’s gait is already smooth and steady. This advice is more relevant for clients who show signs of instability or a tendency to fall.

Correct Answer is C

Explanation

Choice A rationale

Tilting the pelvis forwards and backwards exercises the pelvic joints, not the hinge joints.

Choice B rationale

Turning the head to the right and left exercises the neck joints, not the hinge joints.

Choice C rationale

Bending the arm by flexing the ulnar to the humerus exercises the hinge joints, such as the elbow, which is a hinge joint.

Choice D rationale

Extending the arm at the side and rotating in circles exercises the shoulder joint, which is a ball-and-socket joint, not a hinge joint.

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