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.

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

Apply the cuff above the client's antecubital fossa

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

Answer and Explanation

Correct Answer : A,B

A cuff that is too narrow or too wide can result in inaccurate blood pressure readings. The cuff should be snug but not tight and cover about 80% of the arm length. The pressure should be released at a rate of 2 to 3 mm per second to avoid missing auscultatory gaps or causing discomfort to the client.

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Correct Answer is D

Explanation

The nurse can delegate tasks that are routine, unskilled, and do not require nursing judgment to assistive personnel. Assisting the client to select food choices from the menu is an example of such a task. Evaluating the client's response to pain medication, monitoring the characteristics of the client's chest tube drainage, and teaching deepbreathing and coughing to the client are tasks that require nursing judgment and skill and should not be delegated.

A. Document the largest line the client can read on the chart. B. Begin by testing the client while they are wearing glasses. C. Position the client 3.3m (10 feet) away from the chart D. Instruct the client to begin the assessment with both eyes open.

Correct Answer is B

Explanation

The nurse should begin by testing the client while they are wearing glasses, as this reflects their usual visual acuity. The nurse should document the smallest line that the client can read on the chart, not the largest. The nurse should position the client 6m (20 feet) away from the chart, not 3.3m (10 feet). The nurse should instruct the client to begin the assessment with one eye covered and then switch to cover the other eye.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a chest tube following thoracic surgery. Which of the following tasks should the nurse delegate to assistive personnel?

Correct Answer is D

Explanation

A nurse is assessing the visual acuity of a client who wears glasses using a Snellen chart. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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