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.
Use the palpatory method to determine blood pressure.
Place the arm above the level of the client’s heart.
Deflate the cuff quickly.
The Correct Answer is B
This method involves feeling the radial pulse while inflating and deflating the cuff.
The systolic pressure is estimated by noting the pressure at which the pulse disappears and reappears. The diastolic pressure is not measured by this method, but it can be useful when the sounds are difficult to hear.
Choice A is wrong because applying the largest cuff available can result in a falsely low reading. The cuff size should be appropriate for the client’s arm circumference.
Choice C is wrong because placing the arm above the level of the client’s heart can also cause a falsely low reading. The arm should be at the level of the heart for an accurate measurement.
Choice D is wrong because deflating the cuff quickly can lead to missing or skipping sounds, resulting in an inaccurate reading. The cuff should be deflated slowly and evenly.
Normal ranges for blood pressure vary depending on age, sex, and health conditions, but generally, a systolic pressure below 120 mmHg and a diastolic pressure below 80 mmHg are considered normal for adults.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Absence seizures are brief, sudden lapses of consciousness that usually last a few seconds. They are more common in children than in adults.
A person having an absence seizure may stare blankly into space and not respond to others. They may also have subtle movements such as lip smacking or eyelid fluttering.
Choice B is wrong because absence seizures typically last less than 15 seconds, not 30 to 60 seconds.
Choice C is wrong because absence seizures have a sudden onset, not a gradual one.
Choice D is wrong because absence seizures do not have an aura prior to onset. An aura is a warning sign that some people experience before a seizure, such as a strange feeling, smell, or vision.
Correct Answer is D
Explanation
The correct answer is choice **D. Identify possible precipitating factors related to the infections**.
Choice D rationale:
As a charge nurse concerned about a recent increase in facility-acquired catheter infections, the first step should be to identify possible precipitating factors related to the infections. This involves conducting a thorough investigation to determine the root causes of the increased infection rates. By identifying the underlying factors, the nurse can then develop targeted interventions to address the specific issues and prevent further infections.
Choice A rationale:
While scheduling nursing staff training for infection control procedures is important, it should not be the first action taken. Before implementing training, it is crucial to identify the factors contributing to the increased infection rates to ensure that the training addresses the specific issues at hand.
Choice B rationale:
Meeting with providers to discuss measures to decrease the infections is a necessary step, but it should not be the first action. Providers need to be informed about the situation, but their input will be more valuable once the precipitating factors have been identified.
Choice C rationale:
Revising the current policy for catheter care may be necessary, but it should not be the first action. Policies should be based on evidence-based practices and tailored to address the specific issues identified through the investigation.
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