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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

Administering PRN oral pain medication without further assessment may not be appropriate, as the client’s pain needs must be fully evaluated before intervening with medication. Pain medication should be administered based on an accurate assessment rather than solely on nonverbal cues.

Choice B rationale

Reviewing the pain medications prescribed is important, particularly if the client is exhibiting signs of uncontrolled pain. However, this intervention should be secondary to further assessment of the client’s current pain status.

Choice C rationale

Administering PRN oral pain medication without further assessment may not be appropriate, as the client’s pain needs must be fully evaluated before intervening with medication. Pain medication should be administered based on an accurate assessment rather than solely on nonverbal cues.

Choice D rationale

Asking the client what is causing the grimacing is the correct intervention to implement first. Nonverbal cues, such as grimacing, can indicate the presence of pain, even if the client denies it verbally. By closely monitoring the client’s nonverbal behavior, the nurse can gather additional information about the client’s pain experience and make appropriate interventions based on a comprehensive assessment.

Correct Answer is B

Explanation

Choice A rationale

Reporting any change in urine color is not a priority intervention for a terminally ill client who is weak, mouth breathing, and refusing anything to eat or drink. The focus should be on comfort measures.

Choice B rationale

Keeping mucous membranes moist is essential for comfort in terminally ill clients who are mouth breathing and refusing fluids. This can be achieved by offering ice chips, sips of water, or using a moist cloth.

Choice C rationale

Recording the client’s daily weight is not a priority in this situation as the client is terminally ill and the focus should be on comfort rather than monitoring weight.

Choice D rationale

Maintaining the client in high Fowler’s position is not necessary unless it helps with breathing. The priority is to keep the client comfortable.

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