when auscultating the blood pressure of a 25 year old patient the nurse notices that the phase i korotkoff sounds begin at 200 mm hg at 100 mm hg the
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NCLEX-RN

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1. When auscultating the blood pressure of a 25-year-old patient, the nurse notices that the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg, the Korotkoff sounds muffle. At 92 mm Hg, the Korotkoff sounds disappear. How should the nurse record this patient's blood pressure?

Correct answer: A

Rationale: When auscultating blood pressure, it is crucial to note the points at which Korotkoff sounds change. In adults, the last audible sound indicates the diastolic pressure. In this case, the Korotkoff sounds muffle at 100 mm Hg and disappear at 92 mm Hg. Therefore, the blood pressure should be recorded as systolic/diastolic, which is 200/92. Choices B, C, and D are incorrect because they do not reflect the correct points where the Korotkoff sounds change during blood pressure measurement.

2. A home health nurse is preparing to visit her next client, whom she has never visited before. Which of the following actions indicates the nurse is upholding safety precautions?

Correct answer: D

Rationale: The correct answer is to keep the car windows rolled up when in an unfamiliar environment. This action helps uphold safety precautions for the home health nurse. When visiting a new client in an unfamiliar area, it is essential to ensure personal safety. Keeping the car windows rolled up can prevent potential intruders or unwanted individuals from gaining access to the nurse while in the vehicle. This precaution is important for personal safety and security. Choice A, sending a text to the client to confirm the location of the house, is not directly related to the nurse's safety during the visit. While communication with the client is important, it does not directly address the nurse's safety. Choice B, leaving her purse and valuables on the seat in the car, poses a security risk. It is not advisable to leave valuables visible in the car, as it may attract thieves and compromise the nurse's safety. Choice C, asking the client to keep an extra set of keys, is more related to accessibility and convenience rather than the nurse's safety. While having an extra set of keys may be helpful, it does not directly address safety precautions for the nurse.

3. Which of the following statements best describes footdrop?

Correct answer: B

Rationale: Footdrop results in the foot becoming permanently fixed in a plantar flexion position, not dorsiflexion. This position points the toes downward. The client may be unable to put weight on the foot, making ambulation difficult. Footdrop can be caused by immobility or chronic illnesses that cause muscle changes, such as multiple sclerosis or Parkinson's disease. Choice A is incorrect because footdrop leads to plantar flexion, not dorsiflexion. Choice C is incorrect as it describes a different condition known as 'toe fanning.' Choice D is incorrect as it describes an external rotation of the heel, which is not a characteristic of footdrop.

4. During a seminar on cultural aspects of nursing, the nurse recognizes that the definition stating, "the specific and distinct knowledge, beliefs, customs, and skills acquired by members of a society,"? reflects which term?

Correct answer: B

Rationale: The term that best fits the provided definition, which includes knowledge, beliefs, customs, and skills acquired by members of a society, is 'Culture.' Culture is a broad concept encompassing various aspects of a society's way of life. Norms refer to typical behaviors or rules within a society. Ethnicity pertains to shared traits among a social group, such as origin, religion, language, and traditions. Assimilation involves adopting the dominant culture's characteristics, often through integration or conformity.

5. A registered nurse who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?

Correct answer: C

Rationale: When assigning a floated nurse from another unit to a client in the emergency department, the goal is to choose a patient with minimal anticipated immediate complications. In this scenario, the adolescent with terminal cancer who has been on pain medications and presents with pinpoint pupils and a relaxed respiratory rate of 11 is the most stable option. These assessment findings indicate opioid toxicity, which, while serious, has the least risk of immediate complications compared to the other clients. Choice A involves a middle-aged client experiencing symptoms of possible cardiac issues due to diet pill overdose, which requires urgent intervention. Choice B presents a young adult with concerning symptoms of potential psychosis or substance withdrawal, requiring immediate attention. Choice D involves an elderly client who recently used crack, posing a high-risk situation that requires prompt evaluation and intervention. Therefore, the correct choice is the adolescent with opioid toxicity, as this client has the least immediate risk of complications among the options provided.

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