NursingPlex
    Sign In
    HESI PN EXIT Proctored Exam 2

    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

    Choice A rationale:Continue with the blood pressure assessment. Continuing with the blood pressure assessment without addressing the observed auscultatory gap could lead to an inaccurate reading. It's important to investigate and note the presence of an auscultatory gap before proceeding with the assessment.Choice B rationale:Reposition the stethoscope over the brachial artery. Repositioning the stethoscope may not resolve the issue of hearing silence followed by a Korotkoff sound. It is important to assess the situation further before making adjustments.Choice C rationale:Reinflate the cuff to a higher number. Reinflating the cuff to a higher number without addressing the auscultatory gap can result in an inaccurate reading. The presence of an auscultatory gap should be noted and managed appropriately.Choice D rationale:Note the presence of an auscultatory gap. This is the correct choice. An auscultatory gap is a temporary disappearance of sounds during the blood pressure measurement, and it may indicate underlying cardiovascular issues. The nurse should note its presence, document it, and take appropriate action if necessary.

    🔒 Submit your answer to reveal