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 A

Explanation

The development of erythema (redness) along the path of the vein indicates phlebitis at the IV site. Phlebitis refers to inﬂammation of the vein, often caused by irritation or infection. When phlebitis occurs, the vein becomes inﬂamed and can appear red, warm, and tender to touch. Erythema is a characteristic sign of phlebitis and suggests that the client's IV site has become irritated or infected.

Let's now discuss why the other

Options are not the correct answers:

Coolness of the client's left forearm: Coolness of the forearm is not typically associated with phlebitis. Instead, it may suggest compromised blood ﬂow to the area, such as arterial insufficiency, rather than inﬂammation of the vein.
Pallor of the client's left forearm: Pallor, or paleness, of the forearm is not a typical finding in phlebitis. It usually indicates reduced blood ﬂow or decreased oxygenation to the area, which can be caused by factors other than inﬂammation of the vein.
Pitting edema at the insertion site: Pitting edema refers to the indentation that remains when pressure is applied to an area of swelling and then release. While edema can occur at the insertion site of an IV, it is not a specific indicator of phlebitis. Edema can result from multiple causes, such as ﬂuid overload or localized inﬂammation, and its presence does not necessarily confirm the presence of phlebitis.

In summary, the presence of erythema along the path of the vein is the finding that indicates the development of phlebitis at the IV site. This redness suggests inﬂammation of the vein, which can be caused by various factors including irritation or infection. The other

Options, such as coolness of the forearm, pallor of the forearm, or pitting edema at the insertion site, are not specific indicators of phlebitis and may be associated with diﬀerent underlying conditions or factors.

A. Palpate the abdomen B. Administer an antiemetic. C. Oﬀer pain medication. D. Auscultate bowel sounds.

Correct Answer is D

Explanation

A. Palpate the abdomen: Palpating the abdomen before auscultating bowel sounds could potentially alter the findings by stimulating peristalsis or causing discomfort in the client, particularly in cases of appendicitis or other acute abdominal conditions.

B. Administer an antiemetic:A thorough assessment, including auscultation of bowel sounds, is needed first to rule out conditions like a bowel obstruction or paralytic ileus where antiemetics may be contraindicated.

C. Offer pain medication:Pain medication can mask symptoms and interfere with the nurse's or physician's ability to accurately assess the underlying cause of the client's symptoms, such as appendicitis.

D. Auscultate bowel sounds:Auscultating bowel sounds is the first action the nurse should take because it is a non-invasive assessment that can provide critical information. It helps determine if bowel sounds are present, hyperactive, hypoactive, or absent, which can guide further interventions and diagnostic steps.

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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 monitoring a client who is receiving continuous IV ﬂuid therapy via a peripheral vein in the left forearm. Which of the following findings indicates that the client has developed phlebitis at the IV site?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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