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.
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 A
Explanation
Choice A rationale
Knowing when the client voided following catheter removal is crucial because it indicates the return of the client’s ability to urinate after catheter removal. It helps assess urinary function and determines if the client is experiencing any urinary retention issues, which could potentially lead to complications such as urinary tract infections or bladder distention.
Choice B rationale
The time of the last dose of IV antibiotic administration is important for managing the client’s urinary tract infection, but it is not as immediately relevant as knowing when the client voided after catheter removal to assess urinary function.
Choice C rationale
Intake and output reports for the previous shift are important for assessing fluid balance and renal function, but knowing when the client voided after catheter removal takes precedence as it directly assesses urinary function and the need for further intervention.
Choice D rationale
The color of the urine during catheter removal may provide some insight into the client’s urinary condition, but it is not as critical as knowing when the client voided after catheter removal to assess urinary function.
Correct Answer is D
Explanation
Choice A rationale
Inspecting crutches to ensure rubber tips are intact is important for safety, but it does not indicate an understanding of the proper crutch walking technique. Proper crutch walking involves using the crutches correctly to avoid injury and ensure mobility.
Choice B rationale
Practicing bicep and triceps isometric exercises can help strengthen the muscles needed for crutch walking, but it does not demonstrate an understanding of the actual crutch walking technique. The focus should be on how the crutches are used during walking.
Choice C rationale
Progressing to foot touchdown and weight-bearing of the affected leg is a part of the rehabilitation process, but it does not specifically indicate proper crutch walking technique. Proper crutch walking involves the correct use of crutches to support the body weight.
Choice D rationale
Bearing body weight on the palms of hands during the crutch gait is the correct technique for three-point gait crutch walking. This method ensures that the weight is distributed properly and reduces the risk of injury to the underarms and shoulders.