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. Wrapping the cuff too loosely around the client's arm: A loosely wrapped cuff can cause an inaccurately high reading, not a low one.

B. Positioning the client's arm above heart level: If the client’s arm is positioned above heart level, the blood pressure reading may be inaccurately low. Blood pressure measurements should always be taken with the arm at heart level.

C. Deflating the cuff too slowly: Deflating the cuff too slowly typically leads to an inaccurately high reading, not a low one.

D. Measuring blood pressure right after the client's mealtime: While digestion can sometimes cause a slight drop in blood pressure, it is not typically a significant factor in obtaining an unusually low reading.

A. "I can drink wine in moderation." B. "I will limit my intake of eggs." C. "I will limit my intake of red meat to two times per week." D. "I should cook with olive oil."

Correct Answer is C

Explanation

A. "I can drink wine in moderation." Moderate wine consumption (particularly red wine) is often considered acceptable as part of the Mediterranean diet. This statement does not indicate a need for further teaching.

B. "I will limit my intake of eggs." Eggs can be consumed in moderation on the Mediterranean diet, typically no more than a few times a week. This statement reflects an understanding of the diet and does not indicate a need for further teaching.

C. "I will limit my intake of red meat to two times per week." The Mediterranean diet recommends limiting red meat consumption, but typically to less than two times per week. This statement indicates a need for further teaching as it suggests a higher frequency than recommended.

D. "I should cook with olive oil." Olive oil is a key component of the Mediterranean diet, replacing butter and other fats. This statement reflects correct understanding and does not indicate a need for further teaching.

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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

When a nurse obtains an unusually low blood pressure measurement for a client whose blood pressure is generally elevated, she considers the possibility of a problem with her technique. Which of the following sources of error should she consider as a possible cause of the low reading?

Correct Answer is B

Explanation

A nurse is reinforcing teaching about the Mediterranean diet with a client who is at risk for hypertension. Which of the following statements by the client indicates a need for further teaching?

Correct Answer is C

Explanation

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