A client has come to the clinic for a follow-up assessment that will include a BP reading. To ensure an accurate reading, the nurse confirms that the client has performed which action?
The client has positioned the arm above heart level.
The client has refrained from smoking for at least eight hours.
The client has consumed adequate fluids the day prior
The client has rested quietly for 5 minutes before the reading is taken
The Correct Answer is D
A. The client has positioned the arm above heart level — For an accurate blood pressure reading, the arm should be at heart level. Placing it above the heart can yield a falsely low reading.
B. The client has refrained from smoking for at least eight hours — While avoiding smoking before a BP reading is important, the recommended timeframe is at least 30 minutes, not eight hours.
C. The client has consumed adequate fluids the day prior — Hydration is important for general health, but it does not directly ensure BP accuracy during a reading.
D. The client has rested quietly for 5 minutes before the reading is taken — Resting quietly for at least 5 minutes in a seated position with feet flat and back supported is essential for an accurate BP measurement. Movement or recent activity can temporarily elevate BP and distort the results.
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Related Questions
Correct Answer is B
Explanation
A. "A condom needs to be used for intercourse but is not necessary for oral contact." — HIV can be transmitted through oral sex, although the risk is lower. Condoms or other barriers (like dental dams) are recommended for all forms of sexual contact.
B. "If I use condoms consistently, they are very effective in preventing transmission." —Consistent and correct use of condoms significantly reduces the risk of HIV transmission during all types of sexual activity.
C. "Lambskin condoms are the most effective in preventing transmission?" — Lambskin condoms can prevent pregnancy but do not effectively block viruses like HIV due to their porous nature. Latex or synthetic condoms are recommended.
D. "Condoms are not effective during anal intercourse." — Condoms are effective during anal intercourse when used correctly, and they are strongly recommended because anal sex carries a higher risk for HIV transmission.
Correct Answer is D
Explanation
A. Instruct the client to avoid caffeinated beverages and alcohol — This is helpful in managing symptoms but not the immediate priority.
B. Encourage the client to increase oral fluid intake to 2–3 liters per day — This supports urinary tract health but does not address the active infection directly.
C. Educate the client on proper perineal hygiene and wiping technique — Important for prevention of future infections, but not the most urgent need at this time.
D. Administer the prescribed antibiotic as ordered —The client has clinical signs of a urinary tract infection (UTI) supported by urinalysis findings (positive nitrites and leukocyte esterase). Prompt antibiotic therapy is the priority to relieve symptoms, prevent progression, and treat the infection effectively.
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