A nurse is preparing to obtain a client's blood pressure. Which of the following actions should the nurse take to measure the blood pressure accurately?
Use a cuff of the appropriate size for the client.
Assist the client to the bathroom to void.
Apply the cuff loosely around the client's arm.
Obtain the reading in the early morning.
The Correct Answer is A
A. Use a cuff of the appropriate size for the client:
Using a cuff that is too small or too large can cause inaccurate readings. Proper sizing is crucial.
B. Assist the client to the bathroom to void:
While a full bladder can slightly affect BP, this is not the most essential step to ensure an accurate reading.
C. Apply the cuff loosely around the client’s arm:
A loose cuff will cause an inaccurate (falsely high) reading.
D. Obtain the reading in the early morning:
While BP naturally varies, the time of day is not critical to accurate technique unless part of a specific assessment schedule.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
The findings that require follow-up:
- Redness noted at wound borders, skin surrounding wound is warm to touch
This suggests local infection or inflammation around the wound. - Purulent drainage noted
Purulent (thick, discolored) drainage is a sign of infection and requires prompt follow-up. - Temp 38.9° C (102° F)
This elevated temperature indicates a systemic response, likely due to infection. - WBC 13,500/mm³ (5000 to 10,000 mm³)
This is an elevated WBC count, consistent with infection or inflammation.
Incorrect answers:
- Wound bed is red
A red wound bed in a pressure injury is often a sign of granulation tissue, which is part of the normal healing process, not a concern unless accompanied by other signs of infection. - Hct 37% (37% to 47%)
Hematocrit is within normal limits, and does not indicate concern.
Correct Answer is B
Explanation
A. Hydrofiber dressing:
Hydrofiber dressings are designed for moderate to heavy exudate, not dry or non-exudative wounds.
B. Transparent-film dressing:
Transparent-film dressings are ideal for superficial, non-draining wounds like skin tears. They protect the area while allowing for oxygen exchange and visualization of the wound.
C. Alginate dressing:
Alginate dressings are highly absorbent and used for moderate to heavy exudating wounds, not for dry superficial tears.
D. Foam dressing:
Foam dressings are best for wounds with exudate. They are thicker and may not adhere well to superficial skin tears without drainage.
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