Free NCLEX RN Questions on Health Promotion and Maintenance Nursing Practice Question
When taking Mr. D's blood pressure, the first sound you hear is at 162, and the second sound you hear is at 86. You should document and report that the blood pressure is _____________.
Correct Answer: C
Rationale: The correct answer is C: 162/86. The first sound heard corresponds to the systolic pressure (top number) and the second sound heard corresponds to the diastolic pressure (bottom number). Therefore, the blood pressure is documented as systolic/diastolic. In this case, the first sound at 162 indicates the systolic pressure, and the second sound at 86 indicates the diastolic pressure. Alternatives A (86/162) is incorrect as systolic pressure always comes first. B (irregular and high) is incorrect as the blood pressure values are within normal range. Option D (normal for people of all ages) is incorrect because the blood pressure should be documented as per standard practice, regardless of age.