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 D
Explanation
A. Incorrect. Unused medication replacement might not be necessary every 6 months and depends on the expiration date of the medication container.
B. Incorrect. Dabigatran capsules should not be crushed or opened, as it can affect the medication's efficacy and increase the risk of bleeding.
C. Incorrect. Storing the medication in the refrigerator is not necessary for dabigatran.
D. Correct. Keeping the medication in the original container helps protect it from moisture and ensures proper identification and labeling.
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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