A nurse is assessing a client's blood pressure and finds a significant difference between the blood pressure readings in the client's right and left arms. What action should the nurse take?
Recheck the blood pressure using a different cuff size.
Document the blood pressure findings as the only action required.
Notify the healthcare provider of the significant difference.
Perform a Doppler ultrasound to assess blood flow.
The Correct Answer is C
Answer: c. Notify the healthcare provider of the significant difference.
Explanation: A significant difference in blood pressure readings between the right and left arms may indicate arterial occlusion or other circulatory abnormalities. The nurse should notify the healthcare provider for further evaluation and intervention.
a. Rechecking the blood pressure with a different cuff size may be appropriate if the initial readings were inaccurate, but it does not address the significant difference between the arms.
b. Documenting the finding is important, but further action is required to investigate the cause of the discrepancy.
d. Performing a Doppler ultrasound may be done as part of the diagnostic process to assess blood flow, but the healthcare provider should be notified first for appropriate evaluation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Answer: c. Place the bell of the stethoscope over the brachial artery.
Explanation: To obtain an accurate blood pressure reading, the nurse should place the bell of the stethoscope over the brachial artery, which is located in the antecubital fossa.
a. Inflating the cuff to 20 mmHg above the estimated systolic pressure may be appropriate for initial inflation, but the cuff should be inflated further until the radial pulse disappears, and then slowly deflated to obtain accurate readings.
b. Deflating the cuff at a rate of 2-3 mmHg per second is recommended to obtain accurate blood pressure readings.
d. Palpating the radial artery while auscultating for Korotkoff sounds is not necessary for accurate blood pressure measurement and may interfere with accurate assessment.
Correct Answer is C
Explanation
Answer: c. Swipe the thermometer gently across the client's forehead.
Explanation: Temporal artery thermometers are used by swiping the thermometer gently across the client's forehead. The device measures the temperature of the temporal artery, which correlates with core body temperature.
a. Inserting the thermometer into the rectum is not the appropriate method for using a temporal artery thermometer.
b. Placing the thermometer in the axilla is appropriate for axillary temperature measurement but not for temporal artery thermometers.
d. Holding the thermometer under the tongue is appropriate for oral temperature measurement but not for temporal artery thermometers.
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