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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View Related questions
Correct Answer is A
Explanation
Choice A rationale
Positive external places are often used in guided imagery to help clients focus on pleasant and calming environments. This technique can help distract from pain and promote relaxation by engaging the mind in a soothing and peaceful visualization.
Choice B rationale
Tranquil sounds can also be beneficial in relaxation techniques, but they are not the primary focus in guided imagery for chronic pain. Guided imagery typically involves visualizing a serene place rather than focusing solely on sounds.
Choice C rationale
Emotional reflection may not be as effective in reducing chronic pain through guided imagery. This technique is more about visualizing positive and calming environments rather than reflecting on emotions.
Choice D rationale
Motivational phrases are useful in other therapeutic techniques but are not the primary focus in guided imagery for chronic pain. Guided imagery focuses more on visualizing serene and peaceful places.
Correct Answer is D
Explanation
Choice A rationale
Lubricating the thermometer before inserting it into the ear is not a standard practice for using a tympanic thermometer. Tympanic thermometers are designed to be used without lubrication, and using lubrication could interfere with the accuracy of the reading.
Choice B rationale
Holding the thermometer in place for a full three minutes is unnecessary for tympanic thermometers. These thermometers provide quick readings, usually within a few seconds, and holding it for longer does not improve accuracy.
Choice C rationale
Pulling the client’s auricle down and back is the correct technique for infants and young children. For adults, the correct technique is to pull the auricle up and back to straighten the ear canal for an accurate reading.
Choice D rationale
Using positive reinforcement to affirm that the procedure is being performed correctly is the appropriate action. The UAP is using the correct technique by pulling the client’s auricle up and back, which is the proper method for adults.