Author Question: The nurse enters the client's room and before he can take vital signs, he hears a piercing, ... (Read 23 times)

danielfitts88 · **on:** Jul 23, 2018

The nurse enters the client's room and before he can take vital signs, he hears a piercing, high-pitched sound coming from the client when he breathes. The nurse's initial next best action is to:

a. Document the finding and continue with the assessment
b. Ask the client to take several deep breaths over the next 24 hours
c. Give the client extra fluids to loosen the secretions of mucus
d. Assess the client's airway patency

Question 2

In evaluating a client's blood pressure for hypertension, it would be most important to:

a. Use the same type of manometer each time
b. Auscultate all five Korotkoff sounds
c. Measure the blood pressure in both arms
d. Monitor the blood pressure for a pattern

ktidd · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

D
These sounds are known as stridor and indicate that the client is in respiratory distress or has an obstructed airway. The nurse's initial action is to assess the patency of the airway. Coughing would help if the problem involved rhonchi. Stridor requires an immediate assessment of the client's airway patency.

Answer to Question 2

D
Blood pressure fluctuates a great deal during the day and is influenced by age, sex, activity, and many other factors. Any determination of hypertension must be done after two or more BP readings taken on separate occasions. The type of manometer does not greatly influence the reliability of BP readings. Although more accurate, the manual manometer is being replaced by nonmercury-containing devices, such as the aneroid or electronic blood pressure monitors. Only the first and last Korotkoff sounds are necessary to determine a BP reading. The first time BP is assessed for a patient, the nurse should compare the reading in the left and right arm; however, this is not specific to evaluating for hypertension.