Author Question: The nurse assesses phase 1 Korotkoff's sound occurring at 136 and phase 5 Korotkoff's sound ... (Read 119 times)

HCHenry · **on:** Jul 23, 2018

The nurse assesses phase 1 Korotkoff's sound occurring at 136 and phase 5 Korotkoff's sound occurring at 72. How should the nurse document this client's blood pressure reading?

1. 136/72.
2. 72/136.
3. 136 - 72.
4. 72 - 136.

Question 2

Even though a UAP is available to assist with vital sign assessment, the nurse is going to conduct these assessments himself on which clients?

1. Client complains of chest pain.
2. Client returning from surgery.
3. Prior to administering a medication that affects blood pressure.
4. Client complains of dizziness after ambulating.
5. Client being admitted to the care area.

welcom1000 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 1
Rationale 1: The first tapping phase 1 Korotkoff's sound is the systolic blood pressure. The last sound heard during phase 5 Korotkoff's sound is the diastolic blood pressure. The nurse would document the blood pressure as being 136/72.
Rationale 2: The diastolic blood pressure is not documented before the systolic blood pressure.
Rationale 3: The systolic blood pressure and diastolic blood pressure are not separated by a minus sign.
Rationale 4: This places the diastolic reading first and uses the minus sign, which is incorrect to use.

Answer to Question 2

Correct Answer: 1,2,3,4
Rationale 1: When a client reports symptoms such as chest pain, the nurse should conduct the assessment.
Rationale 2: When a client returns from surgery, the nurse should conduct the assessment.
Rationale 3: When the client is prescribed a medication that could affect the vital signs, the nurse should conduct the assessment.
Rationale 4: When the client reports symptoms such as dizziness after ambulation, the nurse should conduct the assessment.
Rationale 5: When the client is being admitted to a care area, the nurse could delegate the vital sign assessment to the UAP.