A nurse is collecting a blood pressure (BP) reading from a client who is sitting in a chair. The nurse determines that the client's BP is 158/96 mm Hg. Which of the following actions should the nurse take?
Request that another nurse check the client's BP in 30 min.
Reposition the client supine and recheck her BP.
Recheck the client's BP in her other arm for comparison.
Ensure that the width of the BP cuff is 50% of the client's upper arm circumference
The Correct Answer is C
A. Request that another nurse check the client's BP in 30 min:
Waiting for 30 minutes to have another nurse check the blood pressure may not be the most immediate and effective action. If there are concerns about the accuracy of the reading, rechecking the BP in the other arm promptly is a more appropriate and efficient approach.
B. Reposition the client supine and recheck her BP:
Repositioning the client supine is not necessary in this context. Blood pressure can be accurately measured while the client is sitting. Changing the position might not provide relevant information about the accuracy of the blood pressure reading.
C. Recheck the client's BP in her other arm for comparison:
This is the appropriate action. Checking the blood pressure in the other arm can help determine if there is a significant difference between the arms. A significant difference could indicate arterial disease or other issues. It's essential to confirm the accuracy of the blood pressure measurement.
D. Ensure that the width of the BP cuff is 50% of the client's upper arm circumference:
While ensuring the appropriate size of the BP cuff is essential for accurate readings, this option is not directly addressing the current situation of an elevated blood pressure reading. Checking the other arm for comparison is more relevant to assess the accuracy of the measurement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Four-point alternating gait:
This gait involves a more natural and stable walking pattern. However, it requires weight-bearing on both legs, which may not be suitable for a client who can only bear weight on one leg.
B. Swing-through gait:
The swing-through gait is typically used by clients with bilateral lower extremity weakness. It involves swinging both legs through while supporting weight on the crutches. This gait is not suitable for a client who can only bear weight on one leg.
C. Three-point gait:
This gait is appropriate for a client who can only bear weight on one leg. In a three-point gait, the client uses crutches and swings or hops the non-weight-bearing leg forward, landing on the good leg. This gait provides stability and reduces weight-bearing on the affected leg.
D. Two-point alternating gait:
In a two-point alternating gait, the client advances the crutch and the opposite foot simultaneously. This gait is more energy-efficient than the four-point gait but requires weight-bearing on both legs. It is not suitable for a client who can only bear weight on one leg.
Correct Answer is C
Explanation
A. Occupational therapist:
While occupational therapists play a valuable role in stroke rehabilitation, they typically focus on activities of daily living (ADLs), upper extremity function, and adaptive strategies. In the context of frequent coughing during swallowing, the expertise of an SLP is more directly relevant to address potential dysphagia.
B. Physical therapist:
Physical therapists primarily focus on mobility, strength, and balance. While they may be involved in stroke rehabilitation, the issue of coughing during swallowing is more aligned with the scope of practice of a speech-language pathologist.
C. Speech-language pathologist:
This is the correct answer. A speech-language pathologist (SLP) specializes in assessing and treating communication and swallowing disorders. In this case, the client is experiencing coughing when swallowing, indicating a potential swallowing (dysphagia) issue. The SLP can conduct a thorough evaluation of the client's swallowing function and recommend appropriate interventions, such as swallowing exercises or modified diets, to address the coughing and improve safe swallowing.
D. Social worker:
Social workers provide support for psychosocial and community-related issues. While they are crucial members of the interdisciplinary team, they may not have the specific expertise needed to address the swallowing difficulties experienced by the client after a stroke
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