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
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
Choice A reason:
"You might experience altered taste sensations" is the correct statement. When providing teaching to a client about to undergo external radiation therapy for cancer, the nurse should include information about potential side effects and what to expect during the treatment. One common side effect of radiation therapy, especially when the treatment is focused on or near the head and neck region, is altered taste sensations. Radiation can affect the taste buds and lead to changes in how foods taste.
Choice B reason:
"Use rubbing alcohol to remove the ink markings. “The statement is incorrect. The ink markings made on the client's skin are used as reference points for the radiation therapy treatment. It is essential not to remove these markings, as they are crucial for accurate positioning during each treatment session. The nurse should instruct the client not to tamper with the markings, and the radiation therapy team will remove them when they are no longer needed.
Choice C reason:
"Wear a binder over the radiation site." The statement is incorrect. Wearing a binder over the radiation site is not a standard practice during external radiation therapy. The client should be instructed to follow the specific guidelines provided by the radiation therapy team regarding clothing and positioning during treatments. The use of binders or other tight clothing over the treatment area may not be recommended, as it can cause discomfort or interfere with the delivery of radiation.
Choice D reason
"Wash your skin thoroughly with a washcloth after each treatment." Is incorrect statement. During radiation therapy, the skin in the treatment area can become sensitive. It is essential for the client to follow the specific instructions provided by the radiation therapy team regarding skin care. Generally, the client should avoid using harsh soaps or scrubbing the skin vigorously. Instead, they should gently cleanse the area with a mild soap or as directed by their healthcare providers.
Correct Answer is C
Explanation
This statement should be included in the hand-off report because it provides essential information about the patient’s intraoperative status and potential postoperative complications, such as hypovolemia, anemia, or infection. The estimated blood loss (EBL) is an important indicator of the patient’s fluid balance and hemodynamic stability.
Choice A is wrong because “The client was intubated without complications.” is not relevant for the postoperative care of the patient. The intubation status is usually documented in the anesthesia record and does not need to be repeated in the hand-off report unless there were any issues or injuries related to the airway management.
Choice B is wrong because “There was a total of 10 sponges used during the procedure.” is not pertinent for the postoperative care of the patient.
The number of sponges used during the surgery is usually counted and verified by the scrub nurse and the circulating nurse in the operating room to prevent any retained foreign bodies. This information does not need to be communicated to the PACU nurse unless there was a discrepancy or a missing sponge.
Choice D is wrong because “The client is a member of the board of directors.” is not appropriate for the hand-off report.
This statement violates the patient’s privacy and confidentiality and does not contribute to the quality or safety of care. The patient’s role or position in the organization should not influence the hand-off communication or the postoperative care.
A hand-off report is a critical communication tool that facilitates the transfer of care from one provider to another. It should include relevant information about the patient’s medical history, surgical procedure, intraoperative events, postoperative plan, and any concerns or potential problems.
A standardized hand-off tool, such as SBAR (Situation, Background, Assessment, Recommendation), can help improve the consistency, accuracy, and completeness of the hand-off report.
Some normal ranges that may be useful for postoperative care are:
- Blood pressure: 90/60 mmHg to 120/80 mmHg
- Pulse: 60 to 100 beats/min
- Respiratory rate: 12 to 20 breaths/min
- Oxygen saturation: 95% to 100%
- Temperature: 36°C to 37.5°C
- Hemoglobin: 12 to 18 g/dL
- Hematocrit: 36% to 54%
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