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
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Related Questions
Correct Answer is B
Explanation
Rationale:
A) The parent of the adolescent parent may not have legal authority over the infant's medical decisions.
B) An emancipated adolescent parent typically has the legal authority to provide consent for their child's medical procedures.
C) The infant's provider cannot provide consent on behalf of the adolescent parent.
D) The adult sibling of the adolescent parent does not have legal authority unless designated as a legal guardian.
Correct Answer is C
Explanation
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%.
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