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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Musty odor from the foam dressing upon removal:
A musty odor may indicate infection or colonization, not healing. Foam dressings should not have a strong odor unless there is concern for microbial growth.

B. Granulation tissue on the surface of the wound:
Granulation tissue is new connective tissue and capillaries that indicate active healing in a wound bed.

C. Peeling of the edges of the transparent dressing:
This can compromise the seal of the wound VAC and increase infection risk-not a sign of healing.

D. Sanguineous drainage in the suction device:
Some sanguineous drainage can be expected initially, but persistent bloody drainage is not a direct sign of healing.

A. Wound bed is red. B. Redness noted at wound borders, skin surrounding wound is warm to touch C. purulent drainage noted D. Temp 38.9° C (102° F) E. WBC 13,500/mm3 (5000 to 10,000 mm3)

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.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a large wound that has a vacuum-assisted closure device (wound vac) placed over it. Which of the following findings by the nurse, during a dressing change, indicates healing of the wound?

Correct Answer is B

Explanation

Correct Answer is ["B","C","D","E"]

Explanation

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