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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Atrial gallop: An atrial gallop is associated with the S4 heart sound, which occurs before the S1 sound due to the atrial contraction.
B. Ventricular gallop: An S3 heart sound is known as a ventricular gallop and is often a sign of heart failure or fluid overload. It occurs during early diastole when the ventricle fills rapidly.
C. Closing of semilunar valves: The closing of the semilunar valves (aortic and pulmonary) produces the S2 heart sound, not the S3 sound.
D. Closing of the atrioventricular valves: The closing of the atrioventricular valves (mitral and tricuspid) produces the S1 heart sound, not the S3 sound.
Correct Answer is "{\"xRanges\":[54.328125,79.328125],\"yRanges\":[225.5,250.5]}"
Explanation
To palpate the posterior tibial pulse, the nurse should place their fingers just behind the medial malleolus, which is the bony prominence on the inner side of the ankle. This is where the posterior tibial artery passes and is a common site for checking peripheral circulation in the lower extremities.
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