A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?

Wrap the blood pressure cuff snugly around the arm.

Place the client's arm above the level of the heart.

Center the cuff bladder over the brachial artery.

Check the instrument gauge to ensure the reading starts at zero.

Answer and Explanation

The Correct Answer is B

A. Wrap the blood pressure cuff snugly around the arm. Wrapping the cuff snugly ensures an accurate blood pressure reading. This statement does not indicate a need for further instruction.

B. Place the client's arm above the level of the heart. The arm should be at the level of the heart, not above. Placing the arm above the heart can result in falsely low blood pressure readings. This action indicates a need for further instruction.

C. Center the cuff bladder over the brachial artery. Proper placement of the cuff bladder over the brachial artery is necessary for an accurate reading. This statement does not indicate a need for further instruction.

D. Check the instrument gauge to ensure the reading starts at zero. Ensuring the gauge starts at zero before taking a reading is necessary to prevent errors. This statement does not indicate a need for further instruction.

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Correct Answer is B

Explanation

A. Reassuring the partner of a client who sustained a closed head injury: While providing emotional support to family members is important, this is not the first priority. The immediate concern should be a potential physical complication in a client.

B. Collecting data from a client who reports unilateral calf pain when ambulating: Unilateral calf pain can indicate deep vein thrombosis (DVT), which can lead to a pulmonary embolism if left untreated. This is the most urgent situation and requires immediate assessment.

C. Taking a telephone prescription for a client who is to be transferred from PACU: While transferring a client requires coordination, it is not as urgent as assessing for potential life-threatening complications, such as DVT.

D. Reinforcing a client's dressing on an above-the-knee amputation surgical site: While it is important to manage the surgical site, the client with potential DVT requires more immediate attention due to the risk of pulmonary embolism.

A. 42 units B. 32 units C. 14 units D. 28 units

Correct Answer is A

Explanation

A. 42 units: The nurse needs to prepare 14 units of regular insulin and 28 units of NPH insulin, for a total of 42 units. Both insulins can be combined in the same syringe.

B. 32 units: This option underestimates the total units. The correct total is 42 units, not 32.

C. 14 units: This only accounts for the regular insulin dose. The client also requires 28 units of NPH insulin.

D. 28 units: This only accounts for the NPH insulin dose. The client also requires 14 units of regular insulin.

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A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a group of clients on a medical-surgical unit. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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