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 C
Explanation
Rationale:
A) A tepid bath may cause shivering, which can increase the temperature.
B) Aspirin is contraindicated in children due to the risk of Reye's syndrome.
C) Removing the toddler's extra clothing can help lower the body temperature by allowing heat to escape through the skin.
D) Cooling blankets are typically reserved for severe cases of hyperthermia and may not be appropriate or safe for use in a toddler with a moderately elevated temperature.
Correct Answer is D
Explanation
Rationale:
A) An axillary temperature of 37.4°C (99.3°F) is within the normal range for an infant.
B) An apical pulse of 155/min is within the normal range for a 1-month-old infant.
C) A respiratory rate of 40/min is within the normal range for an infant.
D) A blood pressure of 64/40 mm Hg is abnormally low blood pressure for an infant and could indicate shock, dehydration, or infection. The nurse should report this finding to the provider immediately and monitor the infant's vital signs closely.
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