A nurse is preparing to obtain a blood pressure reading from a school-age child. Which of the following actions should the nurse take?
Record the diastolic value as the first Korotkoff sound (K1).
Release the cuff pressure at a rate of about 5 mm Hg/second.
Position the child's arm at the level of the heart.
Select a cuff with a bladder size that is approximately 20% of the child's upper arm circumference.
The Correct Answer is C
Rationale:
A) The diastolic value is recorded as the disappearance of Korotkoff sounds (K5), not the first sound (K1).
B) The cuff pressure should be released at a rate of 2-3 mm Hg/second, not 5 mm Hg/second.
C) Positioning the child's arm at the level of the heart ensures an accurate blood pressure measurement.
D) The cuff bladder size should be approximately 40% of the child's upper arm circumference, not 20%.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A) Providing a low-sodium diet helps manage fluid retention and edema associated with nephrotic syndrome and corticosteroid therapy.
B) Encouraging increased fluid intake may exacerbate edema and fluid retention.
C) Obtaining urine ketone levels is not specifically indicated for managing nephrotic syndrome or corticosteroid therapy.
D) Administering pancreatic enzymes with each meal is not indicated for nephrotic syndrome or corticosteroid therapy.
Correct Answer is D
Explanation
A. Allowing a toddler to button up their own shirt can be frustrating for them as they may not have developed the fine motor skills required for this task, leading to potential distress.
B. Asking toddlers questions that require a "yes" or "no" answer can limit their language development as it does not encourage them to use language expressively.
C. While providing opportunities to share toys with others is important for social development, it is not the most critical aspect of care in this context.
D. Ensuring the toddler has at least one nap during the day is crucial as toddlers need ample sleep for proper development and to prevent overtiredness, which can affect their mood and behavior.
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