A nurse is providing teaching about blood pressure measurement to a client who has hypertension. Which of the following instructions should the nurse include?
Use an electronic device.
Inflate the cuff to 140/90 mmHg.
Place the cuff on the upper arm.
Measure blood pressure after exercise.
The Correct Answer is C
Choice A reason: Using an electronic device is not a reliable method for measuring blood pressure because it may give inaccurate readings due to movement, noise, or battery issues. An electronic device should be calibrated regularly and compared with a manual device.
Choice B reason: Inflating the cuff to 140/90 mmHg is not a correct procedure for measuring blood pressure because it may cause discomfort and false readings. The cuff should be inflated to about 20 to 30 mmHg above the expected systolic pressure or until the pulse disappears.
Choice C reason: Placing the cuff on the upper arm is a correct procedure for measuring blood pressure because it ensures that the cuff is at the same level as the heart and that the brachial artery is compressed. The cuff should be snug and fit around 80% of the arm circumference.
Choice D reason: Measuring blood pressure after exercise is not a good time for measuring blood pressure because it may reflect a temporary increase due to physical activity. Blood pressure should be measured after resting for at least 5 minutes in a quiet and comfortable environment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Offering the client frozen banana as a snack is an appropriate intervention for the nurse to take because it can help reduce nausea and stimulate appetite. Frozen banana is cold, bland, and easy to digest, which are characteristics of antiemetic foods. Frozen banana also provides potassium, vitamin C, and fiber for the client.
Choice B reason: Serving the client hot meals is not an appropriate intervention for the nurse to take because it can worsen nausea and vomiting. Hot meals are aromatic, spicy, and greasy, which are characteristics of emetic foods. Hot meals can also irritate the stomach lining and trigger the gag reflex.
Choice C reason: Avoiding serving sauces or gravies is not an appropriate intervention for the nurse to take because it can cause dehydration and malnutrition. Sauces and gravies are liquid, mild, and moist, which are characteristics of antiemetic foods. Sauces and gravies can also enhance the flavor and texture of bland foods and provide calories and nutrients for the client.
Choice D reason: Discouraging the use of a straw is not an appropriate intervention for the nurse to take because it can prevent adequate fluid intake and hydration. Using a straw can help the client sip small amounts of clear liquids, such as water, ginger ale, or broth, which are antiemetic fluids. Using a straw can also reduce the exposure to odors and tastes that may cause nausea.
Correct Answer is D
Explanation
Choice A reason: Using a washcloth to clean the denture surfaces is not a good practice for denture care because it can damage or scratch the dentures. A washcloth is too rough and abrasive for denture cleaning. A soft-bristled toothbrush or a special denture brush should be used to clean the denture surfaces gently.
Choice B reason: Wiping dentures before storing them in a dry container at night is not a good practice for denture care because it can cause warping or cracking of the dentures. Dentures should be rinsed thoroughly and soaked in water or a denture cleanser solution at night to keep them moist and prevent deformation.
Choice C reason: Flossing dentures as part of daily cleaning is not a necessary practice for denture care because it does not remove plaque or food particles effectively from the dentures. Flossing dentures can also damage or dislodge the artificial teeth or gums. Brushing and rinsing dentures are sufficient for daily cleaning.
Choice D reason: Wrapping gloved fingers with gauze to remove dentures is a good practice for denture care because it can prevent slipping or dropping of the dentures. Gauze provides friction and grip for removing dentures safely and gently. Gloves protect from contamination and infection.
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