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: Reducing the client's sodium intake is an appropriate intervention for the nurse to take because it can help prevent fluid retention and edema, which are complications of heart failure. Sodium intake should be limited to 2 g per day or less for clients who have heart failure.
Choice B reason: Restricting the client's protein intake is not an appropriate intervention for the nurse to take because it can cause malnutrition and muscle wasting, which can worsen heart failure. Protein intake should be adequate to meet the client's nutritional needs and support cardiac function. Protein intake should be about 0.8 to 1.2 g per kg of body weight per day for clients who have heart failure.
Choice C reason: Weighing the client once per week is not an appropriate intervention for the nurse to take because it can delay the detection and treatment of fluid overload, which can worsen heart failure. The client should be weighed daily at the same time and with the same scale and clothing to monitor fluid status and adjust medication dosage.
Choice D reason: Providing the client with three large meals per day is not an appropriate intervention for the nurse to take because it can increase the workload of the heart and cause dyspnea, fatigue, or chest pain, which are symptoms of heart failure. The client should be provided with small, frequent meals that are low in sodium, fat, and cholesterol to reduce cardiac stress and promote digestion.

Correct Answer is A
Explanation
Choice A reason: Tilt your head forward while you eat is a correct instruction for dysphagia. This position can help prevent choking by closing the airway and directing food and fluids to the back of the mouth and throat.
Choice B reason: Obtain your vitamins in liquid form is not a correct instruction for dysphagia. Liquid vitamins can be too thin and watery for people with dysphagia, as they can easily enter the airway and cause aspiration. Vitamins should be taken in pill or chewable form, or crushed and mixed with thickened liquids or pureed foods.
Choice C reason: Cool foods down to room temperature before consuming is not a correct instruction for dysphagia. Food temperature does not affect the risk of choking for people with dysphagia, as long as the food is not too hot or too cold. Food texture and consistency are more important factors for safe swallowing.
Choice D reason: Drink water with each bite of food is not a correct instruction for dysphagia. Water can also be too thin and watery for people with dysphagia, as it can also enter the airway and cause aspiration. Water should be thickened to a nectar-like, honey-like, or pudding-like consistency, depending on the individual's needs and preferences.
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