Psychosocial Integrity NCLEX Questions Quizlet - Nurselytic

Questions 57

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Psychosocial Integrity NCLEX Questions Quizlet Questions

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Question 1 of 5

When taking a client's blood pressure, the nurse is unable to distinguish the point at which the first sound was heard. Which is the best action for the nurse to take?

Correct Answer: C

Rationale: When the nurse is unable to distinguish the point at which the first sound was heard while taking a client's blood pressure, the best action is to deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. Deflating the cuff for this duration allows blood flow to return to the extremity, ensuring an accurate reading on that extremity a second time. Option A of deflating the cuff completely and immediately reattempting the reading could lead to a falsely high reading. Option B, re-inflating the cuff completely and leaving it inflated for 90 to 110 seconds, reduces circulation, causes pain, and may alter the reading. Option D, documenting the exact level visualized on the sphygmomanometer where the first fluctuation was seen, is not a reliable method for assessing blood pressure and does not address the issue of obtaining an accurate reading.

Question 2 of 5

Correct Answer:

Rationale:

Question 3 of 5

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Question 4 of 5

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Question 5 of 5

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When taking a client's blood pressure, the nurse is unable to distinguish the point at which the first sound was heard. Which is the best action for the nurse to take?
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