A nurse is preparing to palpate a client's systolic blood pressure using the brachial artery. After applying the blood pressure cuﬀ to the client's arm, identify the sequence of steps the nurse should follow. (Arrange the steps, placing them in the order of performance. Use all the steps.)

Palpate the brachial pulse site.

Discontinue palpation of the brachial pulse.

Inﬂate the blood pressure cuﬀ to 30 mm Hg beyond where the brachial pulse was last felt.

Deﬂate the blood pressure cuﬀ slowly until the brachial pulse is detected.

Answer and Explanation

The Correct Answer is A, C, B, D

First, the nurse should palpate the brachial pulse site to locate the artery. Next, the nurse should inﬂate the blood pressure cuﬀ to 30 mm Hg beyond where the brachial pulse was last felt. The nurse should then discontinue palpation of the brachial pulse and deﬂate the blood pressure cuﬀ slowly until the brachial pulse is detected. This is the point at which the systolic blood pressure can be read.

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Correct Answer is D

Explanation

A. Explain the techniques of esophageal speech.Although teaching esophageal speech is important, the use of an artificial larynx may be more immediately relevant and easier for the client to learn and use right after surgery.

B. Schedule a support session for the client.While providing emotional support is important, it is not the immediate priority. The client needs to understand how to communicate effectively after the laryngectomy.

C. Determine the client's reading ability.This may be relevant for assessing the client's ability to understand written instructions, but it is not as directly related to their immediate post-operative needs for communication.

D. Review the use of an artificial larynx with the client.This intervention is the priority because the client will need to know how to use an artificial larynx to facilitate communication after losing their natural voice. This understanding is critical for the client’s post-operative adjustment and ability to express themselves.

A. I will use a pumice stone to soften calluses on my feet. B. I will go barefoot just in the house. C. I can apply lotion to my feet if I avoid the area between my toes. D. I can use a heating pad when my feet are cold. E. I can use a heating pad when my feet are cold.

Correct Answer is C

Explanation

The correct answer is that the client can apply lotion to their feet if they avoid the area between their toes. Moisturizing the feet can help prevent dry skin and cracking, which are common problems for people with diabetes. However, it is important to avoid applying lotion between the toes, as this can create a moist environment that promotes the growth of fungus and bacteria¹.

Options a, b and d are not correct statements by the client that indicate an understanding of proper foot care for diabetes. Using a pumice stone to soften calluses on the feet, going barefoot just in the house and using a heating pad when feet are cold are not recommended practices for people with diabetes.

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A nurse is preparing to palpate a client's systolic blood pressure using the brachial artery. After applying the blood pressure cuﬀ to the client's arm, identify the sequence of steps the nurse should follow. (Arrange the steps, placing them in the order of performance. Use all the steps.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurse's priority?

Correct Answer is D

Explanation

A nurse is providing instruction to a client who has diabetes mellitus about foot care. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

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