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 D

Explanation

A. "A heart murmur is a high-pitched sound due to a narrow valve." While some murmurs may be caused by a narrow valve (stenosis), not all murmurs are high-pitched. Murmurs vary in pitch depending on the cause, so this is not a comprehensive explanation.

B. "A heart murmur is an extra sound your heart makes due to blood entering an inflexible chamber." This describes an S3 or S4 sound rather than a murmur. A heart murmur is typically related to turbulent blood flow through valves, not just an inflexible heart chamber.

C. "This means that there is some inflammation around your heart." This statement incorrectly links a murmur to pericarditis or myocarditis, which involve inflammation. A murmur is associated with abnormal blood flow, not inflammation.

D. "This indicates turbulent (chaotic, random fluctuations) blood flow through a valve." A heart murmur is caused by turbulent blood flow, which can occur when blood moves through a valve that is narrow or has regurgitation. This is the correct explanation.

A. To provide analgesia B. To prevent blood clotting C. To reduce inflammation D. To prevent fever

Correct Answer is B

Explanation

A. To provide analgesia: While aspirin can reduce pain, its primary use following a myocardial infarction is not for analgesia. Other medications are used for pain management in this scenario.

B. To prevent blood clotting: Aspirin is prescribed following a myocardial infarction to inhibit platelet aggregation and prevent blood clots, which can reduce the risk of future cardiac events. This is the correct rationale for aspirin use in coronary artery disease.

C. To reduce inflammation: Although aspirin has anti-inflammatory properties, the primary reason for prescribing it after a myocardial infarction is to prevent blood clots, not to reduce inflammation.

D. To prevent fever: Aspirin can reduce fever, but this is not the reason it is prescribed after a myocardial infarction.

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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 reinforcing teaching with an older adult client who has been newly diagnosed with a heart murmur. Which of the following statements should the nurse make?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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