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
Explanation
A.Jogging or any form of vigorous exercise, especially high-impact activities, should generally be avoided for at least 4–6 weeks after retinal surgery. This is because high-impact activities can increase intraocular pressure and potentially disrupt the healing retina. Jogging involves bouncing or jolting movements, which could adversely affect the repair.
B. Bending at the waist places increased pressure on the eye and can disrupt the healing process after retinal surgery. This action increases intraocular pressure and is typically discouraged postoperatively.
C. Light lifting, such as lifting objects under 10 pounds, is typically allowed after several weeks of recovery, once the initial healing has occurred and the client is no longer at risk for increasing intraocular pressure or straining the surgical site.
D. While sewing itself is a low-impact activity, the act of sewing typically involves bending over or placing the head below the waist, which could still increase intraocular pressure. Early postoperative instructions often caution against activities that involve bending or straining the eyes, such as sewing, reading, or watching TV for extended periods.
D. Correct. After surgical repair of a detached retina, clients should avoid activities that might increase intraocular pressure, like heavy lifting or bending at the waist. Activities that do not strain the eye, like sewing, can typically be resumed earlier.
Correct Answer is C
Explanation
A. Incorrect. Napping for an hour during the day can disrupt nighttime sleep.
B. Incorrect. Exercising prior to bedtime can stimulate the body and interfere with falling asleep.
C. Correct. Eating a light snack before bedtime can help prevent waking due to hunger during the night.
D. Incorrect. Staying in bed if unable to fall asleep can lead to frustration and associating the bed with wakefulness.
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