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 B
Explanation
Rationale:
A) It is recommended to use fresh or frozen fruits and vegetables rather than canned due to concerns about added sugars and sodium.
B) Introducing one new food every 5 to 7 days helps identify potential allergies or intolerances and allows the infant's digestive system to adjust to new foods.
C) The amount of solid food introduced initially is typically smaller, usually starting with a teaspoon or so, gradually increasing as the infant gets accustomed to eating solids.
D) Adding rice cereal to a bottle is not recommended as it can increase the risk of choking and does not promote self-feeding skills.
Correct Answer is C
Explanation
Rationale:
A. While spinal fluid analysis may be necessary in some cases, it is not typically used to confirm a diagnosis of acute lymphoid leukemia (ALL).
B. A complete blood count (CBC) may show abnormalities suggestive of leukemia, but it is not definitive for diagnosis.
C. Bone marrow biopsy is necessary to confirm the diagnosis of acute lymphoid leukemia (ALL) by examining the bone marrow for abnormal cells.
D. Bleeding time is not typically used to diagnose acute lymphoid leukemia (ALL); it assesses platelet function.
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