A nurse is preparing to check a client's blood pressure. Which of the following actions should the nurse take?

Use a cuﬀ with a width that is about 60% of the client's arm circumference.

Apply the cuﬀ above the client's antecubital fossa.

Have the client sit with his arm resting above the level of his heart.

Release the pressure on the client's arm 5 to 6 mm per second.

Answer and Explanation

The Correct Answer is A

When checking a client's blood pressure, the nurse should use a cuﬀ with a width that is about 60% of the client's arm circumference. This will help to ensure that the cuﬀ fits properly and provides an accurate reading.

Options b, c, and d are not correct. The cuﬀ should be applied over the client's brachial artery, which is located in the antecubital fossa. The client should sit with their arm resting at the level of their heart, not above it. The pressure on the client's arm should be released at a rate of 2 to 3 mm per second, not 5 to 6 mm per second.

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Correct Answer is A

Explanation

If a nurse is caring for an older adult client who tells the nurse that they have smoked one pack of cigarettes every day for the last 60 years, the next action the nurse should take is to ask what the client knows about the eﬀects of smoking. This will help the nurse assess the client's knowledge and understanding of the risks associated with smoking and provide an opportunity for education.

Option b is incorrect because working with the client to establish a quit date is important but not the next intervention.

Option c is incorrect because suggesting that the client use nicotine gum to facilitate quitting is important but not the next intervention.

Option d is incorrect because referring the client to a local smoking cessation program is important but not the next intervention.

A. Faxing medical information to the client's provider's office B. Teaching the client discharge instructions with his partner present C. Discussing the client's transfer to a long-term care facility with a nurse from another unit D. Giving a telephone report to a surgical nurse when sending the client to the surgical suite

Correct Answer is C

Explanation

The correct answer is that discussing the client's transfer to a long-term care facility with a nurse from another unit is a violation of HIPA

A. HIPAA regulations require that healthcare providers protect the privacy of their clients' personal health information (PHI) and only share it with authorized individuals on a need- to-know basis.

Options a, b and d are not violations of HIPAA. Faxing medical information to the client's provider's office, teaching the client discharge instructions with his partner present and giving a telephone report to a surgical nurse when sending the client to the surgical suite are all acceptable practices under HIPAA regulations.

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A nurse is preparing to check a client's blood pressure. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client who tells the nurse, "I have smoked one pack of cigarettes every day for the last 60 years." Which of the following actions should the nurse take next?

Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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