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
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Correct Answer is D
Explanation
A. A butterfly needle is not typically used for accessing implanted ports.
B. An angiocatheter is not typically used for accessing implanted ports.
C. A 25-gauge needle might be too small for accessing an implanted port.
D. Correct. A noncoring needle (Huber needle) is specifically designed for accessing implanted venous access ports to minimize damage to the port septum and prevent leakage.
Correct Answer is D
Explanation
A. Incorrect. Rubella is not transmitted via airborne routes. Droplet precautions are typically not required for rubella.
B. Incorrect. Koplik spots are a characteristic of measles, not rubella.
C. Incorrect. Aspirin administration is contraindicated in adolescents with viral infections due to the risk of Reye's syndrome.
D. Correct. Rubella is a teratogenic virus that can cause birth defects in pregnant women who are exposed to the virus. Isolation from pregnant staff members is important to prevent potential transmission.
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