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    Hesi RN Exit Proctored ExamQuestion 56
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    Hesi RN Exit Proctored Exam

    After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

    Explanation & Rationale

    A. Noting the presence of an auscultatory gap is essential, as it may indicate that the blood pressure reading could be inaccurately low if not recognized. This helps ensure the accuracy of the blood pressure measurement. B. Repositioning the stethoscope may be necessary if the sounds are unclear, but recognizing the potential auscultatory gap should be prioritized first. C. Re-inflating the cuff may be appropriate if the nurse is unsure about the readings; however, identifying an auscultatory gap is the first step to ensure accurate assessment. D. Continuing with the blood pressure assessment without acknowledging the silence followed by a Korotkoff sound may lead to misinterpretation of the blood pressure readings.

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