HESI Compass 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
Choice A reason: Continuing with the blood pressure assessment without acknowledging the auscultatory gap may result in an inaccurate reading.Choice B reason: Noting the presence of an auscultatory gap is important as it indicates a brief period when Korotkoff sounds disappear and then reappear, which can lead to underestimation of systolic blood pressure and overestimation of diastolic blood pressure if not recognized.Choice C reason: Repositioning the stethoscope may not address the issue of the auscultatory gap and may lead to inaccurate readings.Choice D reason: Re-inflating the cuff to a higher number is unnecessary and may cause discomfort without addressing the auscultatory gap.
🔒 Submit your answer to reveal
Your Progress
Correct0
Incorrect0
Skipped0
Accuracy0%