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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 C

Explanation

Choice A rationale

Telling the parents that their child’s medical information is none of their business is not appropriate. It is important to communicate respectfully and explain the legal status of the emancipated minor.

Choice B rationale

Promising to give the results to the parents as soon as they are back from the laboratory is not appropriate. The nurse should respect the legal status of the emancipated minor and their right to privacy.

Choice C rationale

Informing the parents that the nurse can only give medical information to their child because they are legally an adult is the best response. This explains the legal status of the emancipated minor and respects their autonomy.

Choice D rationale

Telling the parents that the healthcare provider will share the information with them is not appropriate. The nurse should respect the legal status of the emancipated minor and their right to privacy.

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.

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