A nurse is obtaining a client's manual blood pressure and is having difficulty auscultating sounds. Which of the following actions should the nurse take?
Apply the largest cuff available.
Place the arm above the level of the client's heart.
Deflate the cuff quickly.
Use the palpatory method to determine blood pressure.
The Correct Answer is D
A. Incorrect. Avoiding the issue by scheduling the nurses to have fewer shifts together might not address the underlying conflict and could lead to resentment.
B. Incorrect. To auscultate blood pressure accurately, it's essential to follow proper positioning and technique, which typically involves having the client's arm at heart level. Placing the arm above heart level can lead to falsely lower blood pressure readings.
C. Incorrect. While promising more equitable assignments is important, addressing the conflict directly and encouraging collaboration is a more proactive approach.
D. Using the palpatory method, the nurse can feel for the radial pulse while slowly deflating the blood pressure cuff. This helps estimate the systolic blood pressure when Korotkoff sounds are challenging to hear. It provides a rough estimate until clear sounds can be heard and ensures accurate blood pressure measurement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","E"]
Explanation
A. Placenta previa: The client's symptoms do not specifically suggest placenta previa, which is characterized by painless vaginal bleeding, not back pain.
B. Disseminated intravascular coagulation: The client's symptoms and vital signs do not suggest disseminated intravascular coagulation, which is a serious condition characterized by excessive bleeding and clotting throughout the body.
C. Preeclampsia: The presence of uterine contractions, elevated blood pressure, and a potential increase in body temperature can indicate the risk of developing preeclampsia, a condition characterized by high blood pressure and signs of damage to other organ systems, often developing after the 20th week of pregnancy.
D. Sepsis: While the client has an elevated temperature, the symptoms provided do not strongly indicate sepsis. Other signs, such as rapid heart rate, low blood pressure, and changes in mental status, are usually associated with sepsis.
E. Preterm prelabour rupture of membranes (PROM): The client's report of lower back pain, pinkish vaginal discharge, and uterine contractions can raise concern for the risk of preterm prelabour rupture of membranes, where the amniotic sac ruptures before the onset of labor.
F. Seizures: The client's symptoms and information provided do not indicate a risk of seizures. Seizures can be associated with conditions like preeclampsia but are not directly indicated by the client's current assessment.
Correct Answer is B
Explanation
A. Lyme disease is primarily transmitted through ticks.
B. Lyme disease is a communicable disease of public concern and hence reportable
C. Incorrect. Antitoxin is not used for treating Lyme disease. Lyme disease is caused by a bacterium, not a toxin.
D. Incorrect. Skin necrosis is not a common manifestation of Lyme disease. The primary symptoms include fever, fatigue, headache, and a characteristic skin rash known as erythema migrans.
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