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 ["A","C","D","G"]
Explanation
A. "Try using an abdominal support belt." - An abdominal support belt is recommended to provide support to the growing abdomen and can help alleviate backaches that are common during pregnancy.
B. "Take hot showers to help relieve itching." - This statement is incorrect. Hot showers can actually worsen itching and dry out the skin. Lukewarm showers are recommended instead.
C. "Wear loose-fitting clothing." - This statement is correct. Loose-fitting clothing can provide comfort and reduce irritation, especially in areas experiencing itching.
D. "Wear flat or low-heeled shoes." - This statement is correct. Flat or low-heeled shoes provide better support and stability during pregnancy, reducing the risk of falls.
E. "You can douche twice weekly." - This statement is incorrect. Douching is not recommended during pregnancy as it can disrupt the natural balance of vaginal flora and increase the risk of infections.
F. "Eat two large meals a day." - This statement is incorrect. Eating large meals can lead to discomfort and heartburn. It is better to eat frequent smaller meals throughout the day during pregnancy.
G. "You should avoid fried foods." - This statement is correct. Fried foods can exacerbate heartburn and should be avoided to reduce discomfort.
Correct Answer is B
Explanation
A. Incorrect. Encouraging clients to establish a timeline for grieving might not be appropriate or helpful, as grief processes are individual and non-linear.
B. Correct. Coping with changes in family dynamics is a relevant topic for a support group of this nature, as suicide often brings significant family changes.
C. Incorrect. Focusing on preventing suicide is not the primary goal of this support group; coping and healing are more appropriate.
D. Incorrect. Allowing clients to share negative aspects of their relationship can promote emotional healing and understanding, which is essential in this context.
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