NursingPlex
    Sign In
    HESI RN Exit Proctored ExamQuestion 25
    25 / 127
    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. Reinflating the cuff to a higher number may not resolve the issue and can lead to unnecessary discomfort. B. An auscultatory gap occurs when Korotkoff sounds disappear temporarily after being heard and then reappear. Here, the scenario describes silence followed by the first Korotkoff sound, which is normal, not a gap. C. Repositioning the stethoscope over the brachial artery may not help if the auscultatory gap is the issue. D. When measuring blood pressure, it is normal to first hear silence after inflation until the pressure in the cuff falls just below the systolic pressure, at which point the first Korotkoff sound appears. That first sound marks the systolic blood pressure. Therefore, the nurse should continue deflating the cuff and completing the measurement to identify both systolic and diastolic pressures accurately.

    🔒 Submit your answer to reveal